Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers

Oncological outcomes of multimodality treatment for patients undergoing surgery for locally recurrent rectal cancer: A systematic review

BACKGROUND

There are several strategies in the management of locally recurrent rectal cancer (LRRC) with the optimum treatment yet to be established. This systematic review aims to compare oncological outcomes in patients undergoing surgery for LRRC who underwent neoadjuvant radiotherapy or chemoradiotherapy (CRT), adjuvant CRT, surgery only or surgery and intraoperative radiotherapy (IORT).

METHODS

A literature search of MEDLINE, EMBASE and CINAHL was performed for studies that reported data on oncological outcomes for the different treatment modalities in patients with LRRC from January 1990 to January 2022. Weighted means were calculated for the following outcomes: postoperative resection status, local control, and overall survival at 3 and 5 years.

RESULTS

Fifteen studies of 974 patients were included and they received the following treatment: 346 neoadjuvant radiotherapy, 279 neoadjuvant CRT, 136 adjuvant CRT, 189 surgery only, and 24 surgery and IORT. The highest proportion of R0 resection was found in the neoadjuvant CRT group followed by neoadjuvant radiotherapy and adjuvant CRT groups (64.07% vs 52.46% vs 47.0% respectively). The neoadjuvant CRT group had the highest mean 5-year local control rate (49.50%) followed by neoadjuvant radiotherapy (22.0%). Regarding the 5-year overall survival rate, the neoadjuvant CRT group had the highest mean of 34.92%, followed by surgery only (29.74%), neoadjuvant radiotherapy (28.94%) and adjuvant CRT (20.67%).

CONCLUSIONS

The findings of this systematic review suggest that neoadjuvant CRT followed by surgery can lead to improved resection status, long-term disease control and survival in the management of LRRC. However, treatment strategies in LRRC are complex and further comparisons, particularly taking into account previous treatments for the primary rectal cancer, are required.

ACR Appropriateness Criteria® Staging of Colorectal Cancer: 2021 Update

Preoperative imaging of rectal carcinoma involves accurate assessment of the primary tumor as well as distant metastatic disease. Preoperative imaging of nonrectal colon cancer is most beneficial in identifying distant metastases, regardless of primary T or N stage. Surgical treatment remains the definitive treatment for colon cancer, while organ-sparing approach may be considered in some rectal cancer patients based on imaging obtained before and after neoadjuvant treatment. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pretreatment Staging of Colorectal Cancer

Colorectal cancers are common tumors in the United States and appropriate imaging is essential to direct appropriate care. Staging and treatment differs between tumors arising in the colon versus the rectum. Local staging for colon cancer is less integral to directing therapy given radical resection is often standard. Surgical options for rectal carcinoma are more varied and rely on accurate assessment of the sphincter, circumferential resection margins, and peritoneal reflection. These important anatomic landmarks are best appreciated on high-resolution imaging with transrectal ultrasound or MRI. When metastatic disease is suspected, imaging modalities that provide a global view of the body, such as CT with contrast or PET/CT may be indicated. Rectal cancer often metastasizes to the liver and so MRI of the liver with and without contrast provides accurate staging for liver metastases. This article focuses on local and distant staging and reviews the appropriateness of different imaging for both variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Diagnostic Accuracy of CT for Local Staging of Colon Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this article is to determine the accuracy of CT in the detection of tumor invasion beyond the bowel wall and nodal involvement of colon carcinomas. A literature search was performed to identify studies describing the accuracy of CT in the staging of colon carcinomas. Studies including rectal carcinomas that were inseparable from colon carcinomas were excluded. Publication bias was explored by using a Deeks funnel plot asymmetry test. A hierarchic summary ROC model was used to construct a summary ROC curve and to calculate summary estimates of sensitivity, specificity, and diagnostic odds ratios (ORs).

CONCLUSION

On the basis of a total of 13 studies, pooled sensitivity, specificity, and diagnostic ORs for detection of tumor invasion beyond the bowel wall (T3-T4) were 90% (95% CI, 83-95%), 69% (95% CI, 62-75%), and 20.6 (95% CI, 10.2-41.5), respectively. For detection of tumor invasion depth of 5 mm or greater (T3cd-T4), estimates from four studies were 77% (95% CI, 66-85%), 70% (95% CI, 53-83%), and 7.8 (95% CI, 4.2-14.2), respectively. For nodal involvement (N+), 16 studies were included with values of 71% (95% CI, 59-81%), 67% (95% CI, 46-83%), and 4.8 (95% CI, 2.5-9.4), respectively. Two studies using CT colonography were included with sensitivity and specificity of 97% (95% CI, 90-99%) and 81% (95% CI, 65-91%), respectively, for detecting T3-T4 tumors. CT has good sensitivity for the detection of T3-T4 tumors, and evidence suggests that CT colonography increases its accuracy. Discriminating between T1-T3ab and T3cd-T4 cancer is challenging, but data were limited. CT has a low accuracy in detecting nodal involvement.

Role of pelvic exenteration in the management of locally advanced primary and recurrent rectal cancer

AIM

A review of a single-centre experience of pelvic exenteration as a treatment modality for patients with locally advanced primary and recurrent rectal cancer. The perioperative outcomes, morbidity and long term oncological outcomes are reviewed.

MATERIALS & METHODS

Patients undergoing pelvic exenterations for recurrent and locally advanced rectal cancer between 1 January 2006 and 1 August 2012 were identified from a prospective database. All patients underwent pre-operative staging investigations with computed tomography (CT) scan of chest, abdomen and pelvis and pelvic magnetic resonance imaging (MRI). Patients with locally advanced primary rectal cancer were counselled for pre-operative chemoradiation. Structures such as the urinary bladder and female reproductive organs were resected en bloc where indicated with the lesion. Urological or plastic reconstructions were employed where indicated. The primary outcome measured was overall survival and secondary outcomes measured were time to local recurrence (LR) and systemic recurrence. Disease-free survival was examined by the Kaplan-Meier Method (Fig. 1).

RESULTS

Pelvic exenterations were performed in 13 patients with a median age of 59 (range 26-81). The rate of major post-operative complications was 8% (n = 1), where the patient had anastomotic leakage. There were no mortalities in the perioperative period. All patients were operated with curative intent and negative circumferential margins were shown in 9 out of 13 patients (70%). The DFS was 19.4 and the OS was 22.5 months.

CONCLUSION

An aggressive approach with en bloc resection of organs involved provides survival benefit to patients with locally advanced primary and recurrent rectal cancer with an acceptable morbidity profile.

ACR Appropriateness Criteria pretreatment staging of colorectal cancer

Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Colon cancer: comprehensive evaluation with 64-section CT colonography using water enema as intraluminal contrast agent-a pictorial review

Sixty-four-section CT colonography with water enema combines intracolonic neutral contrast agent with high-resolution CT images of the abdomen. Owing to submillimeter isotropic voxels, high-quality reformatted images are obtained. High-resolution images offer added value for the detection and localization of colonic lesions, evaluation of the local extent of the disease, and depiction, if any, of synchronous colorectal lesions and distant metastases. Sixty-four-section CT colonography with water enema has a major role in the evaluation of patients with colon cancer before planning therapy. It can be used to complement failed or incomplete colonoscopy and investigate the colon in elderly patients.

Pelvic colorectal recurrence: crucial role of radiologists in oncologic and surgical treatment options

Radical resection is the only potential cure for patients with locally advanced primary and recurrent rectal cancer and is considered curative only when the histologic margins are clear of tumour. Early diagnosis of the disease is essential as it increases the likelihood of a potentially curative resection and prevention of dissemination. Clinical examination, tumour markers and radiologic modalities such as ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography are routinely used in an effort to accurately stage these patients and provide useful information for the selection of patients for further treatment/management. This review describes the methods of staging patients with locally advanced primary and recurrent rectal cancer prior to surgery emphasizing the role that radiologists have in this process.

Complete pathological response to bevacizumab and chemoradiation in advanced rectal cancer

BACKGROUND

Localized rectal cancer responds well to 5-fluorouracil and radiation-based regimens. A phase I-II trial is currently testing the efficacy of adding bevacizumab, a VEGF-specific antibody, to standard chemoradiotherapy. The case presented here is a complete pathological response seen in a patient with extensive and locally invasive carcinoma after receiving this combined treatment.

INVESTIGATIONS

Physical examination, rectal ultrasound, PET-CT scan, laboratory tests, proctoscopic examination, chest radiograph, rectal forcep biopsies with immunohistochemistry, and protein and flow cytometric analyses.

DIAGNOSIS

Large, invasive, ultrasound stage T4 carcinoma of the rectum, which was positive for survivin.

MANAGEMENT

One 2-week cycle of bevacizumab alone, followed by 3 cycles of bevacizumab with continuous 5-fluorouracil infusion, and external-beam radiation therapy given 5 days per week to the pelvis, abdominoperineal resection with posterior vaginectomy, hysterectomy and bilateral salpingo-oophorectomy.

Surgery for local recurrence of rectal cancer

OBJECTIVE

Despite improvement in management of primary rectal cancer, 2.6-32% of patients develop local recurrence. A proportion of these patients can be amenable to salvage surgery. The present article reviews the evidence for and against the surgical management for local recurrence of rectal cancer, the role of adjuvant and intraoperative radiotherapy (IORT), and evaluates short and long-term outcomes.

METHOD

A literature search was performed using Medline, Embase, Ovid and Cochrane database for studies between 1980 and 2005 assessing surgical management of local recurrence of rectal cancer and the evidence was critically evaluated.

RESULTS

Nearly 50% of rectal cancer recurrences are local and are therefore potentially amenable to curative resection. Preoperative imaging is important for appropriate selection of patients for surgery and preoperative adjuvant therapy is essential. Five-year survival following resection ranges from 18% to 58% with 5-year survival following complete resection of over 35% though morbidity ranges from 21% to 82%. Neoadjuvant radiotherapy is beneficial and IORT may have a contributory role in treatment. Aggressive surgical treatment favourably affects quality of life and is cost effective. Surgery for local recurrence can result in significant long-term survival with acceptable morbidity and improved quality of life in appropriately selected patients. Assessment in a specialist centre familiar with these techniques is essential.

Abdominal Sacral Resection for Posterior Pelvic Recurrence of Rectal Carcinoma: Analyses of Prognostic Factors and Recurrence Patterns

BACKGROUND

Local recurrence of rectal cancer presents challenging problems. Although abdominal sacral resection (ASR) provides pain control, survival prolongation, and possibly cure, reported morbidity and mortality are still high, and survival is still low. Thus, appropriate patient selection and adjuvant therapy based on prognostic factors and recurrence patterns are necessary. The purpose of this study was to evaluate the results of ASR for posterior pelvic recurrence of rectal carcinoma and to analyze prognostic factors and recurrence patterns.

METHODS

Forty-four patients underwent ASR for curative intent in 40 and palliative intent in 4 cases. All but one could be followed up completely. Multivariate analyses of factors influencing survival and positive surgical margins were conducted.

RESULTS

Morbidity and mortality were 61% and 2%, respectively. Overall 5-year survival was 34%. The Cox regression model revealed a positive resection margin (hazard ratio, 10 [95% confidence interval, 3.8-28]), a local disease-free interval of <12 months (4.2 [1.8-9.8]), and pain radiating to the buttock or further (4.2 [1.6-11]) to be independently associated with poor survival. The logistic regression model showed that macroscopic multiple expanding or diffuse infiltrating growths were independently associated with a positive margin (7.5 [1.4-40]). Of the patients with recurrence, 56% had failures confined locally or to the lung.

CONCLUSIONS

ASR is beneficial to selected patients in terms of survival. To select patients, evaluation of the resection margin, the local disease-free interval, pain extent, and macroscopic growth pattern is important. To improve survival, adjuvant treatment should be aimed at local and lung recurrences.

Transvaginal Sonography as an Adjunct to Endorectal Sonography in the Staging of Rectal Cancer in Women

OBJECTIVE

The purpose of this study was to evaluate the contribution of transvaginal sonography (TVS) in the staging of rectal cancer in women.

MATERIALS AND METHODS

Sixty women with rectal tumors underwent TVS. Forty-five of the 60 women also underwent endorectal sonography. Forty-nine of the women had rectal carcinoma; nine, tubulovillous adenoma; and two, gastrointestinal stromal tumor confirmed at surgical pathologic examination (n = 41) and biopsy before chemoradiation therapy (n = 19). Four of the 49 rectal carcinomas were T1; seven, T2; 35, T3; and three, T4. Images from TVS and endorectal sonography were shown independently to two blinded reviewers, who staged the tumors and assessed examination adequacy for tumor presence, size, and depth and nodal status. Staging results with TVS were compared with those obtained with endorectal sonography and histopathologic examination.

RESULTS

All tumors were seen with TVS. In 30 of the 49 rectal carcinomas confirmed at surgical pathologic examination TVS tumor staging was accurate in 25 (83.3%) of the cases. Two (6.7%) of the 30 tumors were understaged, and 3 (10%) were overstaged. All tumors selected for chemoradiation (n = 19) were correctly staged T3. Endorectal sonography was suboptimal for tumors that were stenotic (n = 3), large (n = 2), high at the rectosigmoid junction (n = 4), or low at the anal canal (n = 3). In these 12 cases, TVS successfully depicted the lesion, and the images gave enough information for prediction of stage. In interpretation of the images of 45 patients who underwent both TVS and endorectal sonography, the blinded reviewers had good agreement and comparable accuracy for staging in adequate examinations with each technique. Four of the nine villous adenomas were overstaged as T1 on TVS. Gastrointestinal stromal tumors manifested as intramural vascular masses.

CONCLUSION

TVS is an excellent adjunct to endorectal sonography in the staging of rectal cancer in women. It helps resolve the findings after endorectal sonography has been unsuccessful because the tumors are stenotic or in a high or low position.

Fusion image of positron emission tomography and computed tomography for the diagnosis of local recurrence of rectal cancer

BACKGROUND

The aim of this study was to evaluate the clinical and therapeutic value of digital fusion image (FI) of positron emission tomography (PET) using (18)F-fluorodeoxy glucose and computed tomography (CT) in patients who were suspected of having a local recurrence of rectal cancer.

METHODS

Forty-two patients (32 men and 10 women; mean age, 61.4 years, range, 40-79 years) with a suspicion of local recurrence after curative resection of rectal cancer were prospectively recruited and underwent (18)F-fluorodeoxy glucose-PET and CT. The FI was reconstructed with a commercially available digital software program, T-B Fusion. Wilcoxon signed rank test was used to compare FI with CT alone or PET alone.

RESULTS

FI yielded a correct diagnosis in 39 (93%) of 42 patients, whereas CT alone and PET alone did so in 33 (79%) and 37 (88%) patients, respectively. FI had better diagnostic accuracy than CT alone (P = .0138) and PET alone (P = .0156). Overall, FI altered patient management in 11 (26.2%) patients on the basis of additional information, including differentiation of the tumor from the postoperative scar in 6 patients, exact anatomical location in 3 patients, and both in 2 patients.

CONCLUSIONS

FI has a potential clinical value in the treatment of suspected local recurrence of rectal cancer.

Colorectal cancer pelvic recurrences: determinants of resectability

PURPOSE

This study was designed to identify preoperative and intraoperative features of locally recurrent colorectal cancer that predict R0 resection in patients scheduled for attempted complete resection followed by intraoperative radiation therapy.

METHODS

Review of a prospective data base identified 119 patients brought to the intraoperative radiation therapy suite for planned complete resection of locally recurrent rectal (n = 101) and colon (n = 18) cancer between January 1994 and November 2000. R0 resection was achieved in 61 patients. This group was compared with patients in which an R1 (n = 38), R2 (n = 7), or palliative procedure (n = 13) was performed. Variables evaluated included: tumor location, features of the primary tumor, and preoperative findings on computed tomography, magnetic resonance imaging, and history/physical. Tumor location was established by review of operative/pathologic reports and classified as axial (anastomotic/perineal), anterior (bladder/genitourinary organs), posterior (presacral), or lateral (pelvic sidewall).

RESULTS

When recurrence was confined to the axial location only, or axial and anterior locations, R0 resection was achieved significantly more often than when other locations were involved (P < 0.001, P = 0.003, respectively). When a lateral component was present, R0 resection was achieved significantly less often than when there was no lateral component (P = 0.002). For patients with available preoperative computed tomography and/or magnetic resonance imaging results (n = 70), the finding of lateral tumor involvement was associated with R0 resection significantly less often than when lateral disease was not identified (P = 0.004).

CONCLUSIONS

Pelvic recurrences confined to the axial location, or axial and anterior locations, are more likely to be completely resectable (R0) than those involving the pelvic sidewall. Efforts to enhance preoperative identification and imaging of these patients are clearly justified.

New indications for computer-assisted surgery: tumor resection in the pelvis

The resection of recurrent malignant pelvic tumors was supported by a commercially available navigation system in three patients. Preoperatively three-dimensional images from the pelvis were obtained by computed tomography or magnetic resonance imaging to identify the tumor extension. During surgery navigated tools oriented the surgeon to excise the tumor with adequate virtual margins. Navigation was helpful for tumor identification in one patient with a recurrent presacral mesenchymal chondrosarcoma. In the other two patients the tumor resection in the bone was done with three-dimensional observation of the osteotomies in the sacrum. In all three patients the histopathologic analysis confirmed that the neoplasms were excised accurately within their margins. We think that computer-assisted surgery is a potential method to increase the accuracy of tumor resections.

Preoperative staging of colorectal cancer--computed tomography and magnetic resonance imaging

Cross-sectional imaging techniques are increasingly being used in the preoperative evaluation of patients with colorectal cancer. Both computed tomography (CT) and magnetic resonance (MR) imaging have been improved with significant advances of the technological hard- and software. This has contributed to high patient acceptance due to shorter examination times and more open configuration of the systems, consistent high quality images with better delineation of the normal abdomino-pelvic anatomy and pathology. New techniques such as CT-colonography have emerged from a research application to a clinical tool which can be used in different clinical settings. Phased-array receiver coils have significantly increased the usefulness of MR in the evaluation of rectal neoplasms due to the high resolution that can be obtained. New organ specific contrast agents for magnetic resonance imaging have facilitated the preoperative evaluation of liver metastases in favour of more invasive techniques with similar sensitivities. However, preoperative staging criteria for colorectal cancer using computed tomography and magnetic resonance imaging has to be updated and the results of new techniques have to be confirmed in large trials. In the future, further development of CT and MR may offer 'one-stop-shopping' protocols for both diagnosis, local and distant staging of colorectal cancer. Diffusion weighted MR-imaging, in vivo spectroscopy as well as further targeted imaging, such as with lymph node specific agents for MR may also prove to be helpful in the preoperative evaluation of patients with colorectal cancer.

Pre-operative radiochemotherapy of locally advanced rectal cancer

AIM: To evaluate results of pre-operative radiochemotherapy followed by surgery for 15 patients with locally advanced un-resectable rectal cancer.

METHODS: 15 patients with advanced non-resectable rectal cancer were treated with pre-operative irriadiation of 40-46 Gy plus concomitant chemotherapy (5-FU + LV and 5’-DFuR) (RCS group). For comparison, 27 similar patients, treated by preoperative radiotherapy (40-50 Gy) plus surgery were served as control (RS group).

RESULTS: No radiochemotherapy or radiotherapy was interrupted and then was delayed because of toxicities in both groups. The radical resectability rate was 73.3% in the RCS group and 37.0% (P = 0.024) in RS group. Sphincter preservation rates were 26.6% and 3.7% respectively (P = 0.028). Sphincter preservation rates of lower rectal cancer were 27.3% and 0.0% respectively (P = 0.014). Response rates of RCS and RS groups were 46.7% and 18.5% (P = 0.053). The tumor downstage rates were 8 (53.3%) and 9 (33.3%) in these groups (P = 0.206). The 3-year overall survival rates were 66.7% and 55.6% (P = 0.485), and the disease free survival rates were 40.1% and 33.2% (P = 0.663). The 3-year local recurrent rates were 26.7% and 48.1% (P = 0.174). No obvious late effects were found in either groups.

CONCLUSION: High resectability is possible following pre-operative radiochemotherapy and can have more sphincters preserved. It is important to improve the quality of the patients’ life even without increasing the survival or local control rates. Preoperative radiotherapy with concomitant full course chemotherapy (5-Fu + LV and 5’-DFuR) is effective and safe.

Radiologic imaging modalities in the diagnosis and management of colorectal cancer

Colorectal carcinoma poses a serious public health threat. Detection in its early stages in the best predictor for long-term survival, which is the impetus for population-based screening programs. We believe that full-colon imaging by either DCBE or colonoscopy is necessary for colon cancer screening because flexible sigmoidoscopy, even if perfect, only detects 50% to 60% of colon cancers, a rate far worse than even the worst rate reported for single-contrast barium enema. Screening for colon cancer with flexible sigmoidoscopy is equivalent to performing a "left" mammogram for the detection of breast cancer. The role of CT colonography is still to be determined. When confronted with a symptomatic patient, barium enema is applied in conjunction with CT to detect primary colorectal carcinoma, to differentiate it from other benign and malignant processes involving the colon, and to assess for disease extent before surgery in selected high-risk patient populations. Pelvic MRI may be useful in the preoperative assessment of patients with rectal carcinoma as a means for assisting surgical planning. CT, MRI, and barium enema are used in postoperative follow-up for detecting local recurrence and distant spread. In response to known difficulty in discriminating between normal postoperative changes and tumor recurrence and in determining the nature of certain liver lesions, FDG-PET has been approved for the detection and localization of recurrent colorectal cancer in patients with rising CEA levels and indeterminate findings on standard imaging studies. Given its current promise of offering high sensitivity, specificity, and accuracy, the indications for PET may well expand in the future, but its final role in still to be determined.

Recurrent or residual pelvic bowel cancer: accuracy of MRI local extent before salvage surgery

PURPOSE

To determine pre-operative MRI accuracy in assessing local disease extent in recurrent/residual pelvic bowel cancer by comparing MRI assessment and staging examination under anaesthesia (EUA), with laparotomy/histopathological findings.

MATERIALS AND METHODS

Twenty-seven consecutive patients with recurrent (n = 21) or residual (n = 6) pelvic bowel cancer (13 of the rectum, eleven of the anus and three of the colon) underwent EUA and pelvic MRI (1T) using a phased array pelvic coil. Retrospective analysis of eight specific anatomical regions for tumour involvement on MRI was performed. Findings at EUA and biopsy were recorded. The MRI and EUA findings were correlated with findings at surgery and histopathology. Statistical comparison between MRI and EUA results was performed using the chi-squared test.

RESULTS

Overall MRI accuracy in determining tumour invasion for all sites assessed was 452/499 (91%), sensitivity was 95/109 (87%), specificity was 357/390 (92%), positive predictive value (PPV) was 95/128 (74%) and negative predictive value (NPV) was 357/371 (96%). PPV and NPV for specific areas were 21/38 (55%) and 134/136 (99%) for genitourinary tract, 4/6 (67%) and 61/65 (94%) for pelvic side wall, 21/26 (81%) and 40/41 (98%) for pelvic floor, 1/6 (17%) and 40/43 (93%) for the posterior pelvis pre-sacrum/sacrum. For those anatomical sites evaluated by both EUA and MRI, MRI was superior to EUA, with an accuracy of 89% vs 73% (P < 0.05).

CONCLUSION

MRI is an accurate technique for assessing disease extent in recurrent/residual pelvic bowel cancer.

Locally recurrent rectal cancer

Local recurrence (LR) varies from less than 4% to greater than 50%; several tumor factors and operative techniques may influence rate of LR. Of greatest interest has been the considerable inter-surgeon variation, even within the same institution. An LR rate of less than 10% has been consistently reported by those who use total mesorectal excision even without any form of adjuvant therapy, either preoperatively or postoperatively. These findings raise important questions about surgical technique, subspecialty teaching, place of adjuvant therapy and quality assurance. The management of LR by a multispecialty team and multimodality treatment including preoperative chemoradiation, surgical resection and intraoperative radiotherapy provides encouraging results in terms of better local control and prolonged survivorship in carefully selected patients. These uncontrolled results justify further evaluation of these salvage operations in a more controlled manner that should include repercussions on the quality of life of the patients.

Patterns of pelvic invasion are prognostic in the treatment of locally recurrent rectal cancer

BACKGROUND

Local recurrence of rectal cancer after curative resection remains a difficult clinical problem. The aim of this study was to elucidate prognostic risk factors after resection of recurrent cancer.

METHODS

Between January 1983 and December 1999, 83 patients with locally recurrent rectal cancer were studied retrospectively for survival benefit by re-resection. Sixty patients underwent resection for recurrent cancer, including total pelvic exenteration in 30 patients and sacrectomy in 23 patients. The extent of locally recurrent tumour was classified by the pattern of pelvic invasion as follows: localized, sacral invasion and lateral invasion.

RESULTS

Multivariate analysis showed that the pattern of pelvic invasion was a significant prognostic factor which independently influenced survival after resection of recurrent cancer (P < 0.001). The 5-year survival rates were 38 per cent in the localized type (n = 27), 10 per cent in the sacral invasive type (n = 16) and zero in the lateral invasive type (n = 17).

CONCLUSION

Resection for locally recurrent rectal cancer is potentially curative in patients with localized or sacral invasive patterns of recurrence. Alternatives should be explored in patients with recurrence involving the lateral pelvic wall.

Staging of colorectal cancer

CT, MR, and TRUS play complementary roles in staging CRC. Further improvements in these techniques will improve the accuracy of preoperative staging and thereby help optimize patient treatment and outcome.

Sacropelvic resection for recurrent anorectal cancer. A multidisciplinary approach

A multimodal approach including preoperative external beam radiation, surgical resection, and intraoperative electron radiation was used in 23 patients with locally advanced anal or recurrent rectal cancers involving the sacrum. The proximal extent of complete sacral resection was S2 in three patients, S3 in 12 patients, S4 in two patients, and S5 in one patient. The tumor was confined to the anterior sacral cortex in five patients. The resection was marginal in 10, contaminated marginal in 11, and intralesional in two patients. At 19 to 54 months of followup, five patients are alive without evidence of disease and four are alive with disease. Twelve patients died of their disease, and two died of other causes. There was a mean survival of 32.9 months for the patients who were alive at followup. Kaplan-Meier survival for all patients was 82% at 1 year and 73% at 2 years, with death of disease as an endpoint. Thirteen (57%) patients had another local recurrence develop at a mean of 17.2 months. Eight (35%) patients had metastatic disease develop at a mean of 16.3 months. Proper patients selection is important in ensuring a favorable outcome from this aggressive surgery.