Endoscopic ultrasound staging of rectal cancer: diagnostic value before and following chemoradiation

The Optimal Application of Transrectal Ultrasound in Staging of Rectal Cancer Following Neoadjuvant Therapy: A Pragmatic Study for Accuracy Investigation

Background: Transrectal ultrasound (TRUS) is a cost-effective test for preoperative assessment of rectal cancer. However, whether the accuracy of TRUS staging is correlated with tumor location remains obscured. This study is designed to explore their relationship and confirm an optimal application of TRUS in rectal cancer restaging.

Methods: From 2005 to 2011, rectal cancer patients with TRUS data were retrospectively reviewed. Patients were divided into five groups according to tumor-involved rectal segment (SEG) above the anal verge: SEG I 1-3cm, II 3-6cm, III 6-9cm, IV 9-12cm, and V 12-16cm. The accuracy and long-term outcomes of tumor staging were compared between ultrasonographic and pathological stages.

Results: 219 patients were included, with 55 (25.1%) in SEG I, 123 (56.2%) in SEG II, 32 (14.6%) in SEG III, 4 (1.8%) in SEG IV and 5 (2.3%) in SEG V. The overall accuracy of TRUS staging was remarkably superior to clinical staging by CT (64.8% vs. 34.7%, P<0.001), with 70.3% and 82.2% for ultrasonographic T and N stages respectively. The accuracy of TRUS reached its peak value when tumors were located in SEG II. The 5-year overall survival had no significant difference between TRUS and pathology staging for all stages. A cox regression analysis indicated that high levels of CEA and tumor location were risk factors of inaccurate staging.

Conclusions: TRUS is still a valuable examination for restaging of rectal cancer after neoadjuvant therapy. The application of TRUS would be optimal for rectal cancer located 3-6cm above the anal verge.

Endoscopic diagnosis of primary anorectal melanoma

OBJECTIVE

The present study retrospectively analyzed case data from 12 patients diagnosed with anorectal melanoma, with the purpose of identifying key diagnostic features at endoscopy.

MATERIALS AND METHODS

Images from colonoscopy were reviewed for all patients in order to establish the endoscopic features of primary anorectal melanoma. For the patients whose colonoscopic examinations included endoscopic ultrasound, images were examined to characterize lesions and the depth of infiltration, the results of which were compared with pathological findings after operative resection.

RESULTS

At colonoscopy, superficial melanin pigmentation was identified in 10 patients with anorectal melanoma, with morphology including spots, patches, or sheets of pigmentation. In patients who underwent endoscopic ultrasound, lesions appeared as masses on the mucosal side with inhomogeneous or low-level internal echoes or ulcer-type lesions invading the muscularis propria. Lesions diagnosed as anorectal melanoma also demonstrated irregular margins and varying degrees of submucosal infiltration. Infiltration depth of melanoma via endoscopic ultrasound (EUS) was concordant with surgical pathology results in 100% of patients.

CONCLUSION

Colonoscopy combined with biopsy and subsequent pathological examination can accurately diagnose primary anorectal melanoma. Moreover, EUS is a reliable tool for assessing the depth of infiltration of this disease.

Endoscopic ultrasound in oncology: An update of clinical applications in the gastrointestinal tract

An accurate staging is necessary to select the best treatment and evaluate prognosis in oncology. Staging usually begins with noninvasive imaging such as computed tomography, magnetic resonance imaging or positron emission tomography. In the absence of distant metastases, endoscopic ultrasound plays an important role in the diagnosis and staging of gastrointestinal tumors, being the most accurate modality for local-regional staging. Its use for tumor and nodal involvement in pre-surgical evaluation has proven to reduce unnecessary surgeries. The aim of this article is to review the current role of endoscopic ultrasound in the diagnosis and staging of esophageal, gastric and colorectal cancer.

Learning curve for endorectal ultrasound in young and elderly: lights and shades

Aim of the study is to highlight difficulties faced by an inexperienced surgeon in approaching endorectal-ultrasound, trying to define when learning curve can be considered complete. A prospective analysis was conducted on endorectal-ultrasound performed for subperitoneal rectal adenocarcinoma staging in the period from January 2008 to July 2013, reported by a single surgeon of Department of Oncology, Section of General Surgery, "San Luigi Gonzaga" Teaching Hospital, Orbassano (Turin, Italy); the surgeon had no previous experience in endorectal-ultrasound. Fourty-six endorectal-ultrasounds were divided into two groups: early group (composed by 23 endorectal-ultrasounds, made from January 2008 to May 2009) and late group (composed by 23 endorectal-ultrasound, carried out from June 2009 to July 2013). In our experience, the importance of a learning curve is evident for T staging, but no statystical significance is reached for results deal with N stage. We can conclude that ultrasound evaluation of anorectal and perirectal tissues is technically challenging and requires a long learning curve. Our learning curve can not be closed down, at least for N parameter.

Definitive Chemoradiotherapy ("Watch-and-Wait" Approach)

Preoperative chemoradiotherapy (CRT) followed by total mesorectal excision has been the standard of care for locally advanced patients with rectal cancer. Some patients achieve a pathologic complete response (pCR) to CRT and the oncologic outcomes are particularly favorable in this group. The role of surgery in patients with a pCR is now being questioned as radical rectal resection is associated with significant morbidity and long-term effects on quality of life. In an attempt to better tailor therapy, there is an interest in a "watch-and-wait" approach in patients who have a clinical complete response (cCR) after CRT with the goal of omitting surgery and allowing for organ preservation. However, a cCR does not always indicate a pCR, and improved clinical and imaging modalities are needed to better predict which patients have achieved a pCR and therefore can safely undergo a "watch-and-wait" approach. This article reviews the current data on nonoperative management and on-going controversies associated with this approach.

Rectal Tumour Staging with Endorectal Ultrasound: Is There Any Difference between Western and Eastern European Countries?

Background. Rectal tumour management depends highly on locoregional extension. Rectal endoscopic ultrasound (ERUS) is a good alternative to computed tomography and magnetic resonance imaging. However, in Hungary only a small amount of rectal tumours is examined with ERUS. Methods. Our retrospective study (2006-2012) evaluates the diagnostic accuracy of ERUS and compares the results, the first data from Central Europe, with those from Western Europe. The effect of neoadjuvant therapy, rectal probe type, and investigator's experience were also assessed. Results. 311 of the 647 ERUS assessed locoregional extension. Histological comparison was available in 177 cases: 67 patients underwent surgery alone; 110 received neoadjuvant chemoradiotherapy (CRT); ERUS preceded CRT in 77 and followed it in 33 patients. T-staging was accurate in 72% of primarily operated patients. N-staging was less accurate (62%). CRT impaired staging accuracy (64% and 59% for T- and N-staging). Rigid probes were more accurate (79%). At least 30 examinations are needed to master the technique. Conclusions. The sensitivity of ERUS complies with the literature. ERUS is easy to learn and more accurate in early stages but unnecessary for restaging after CRT. Staging accuracy is similar in Western and Central Europe, although the number of examinations should be increased.

The accuracy of MRI, endorectal ultrasonography, and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy: A metaanalysis

BACKGROUND

To perform a metaanalysis to determine and compare the diagnostic performance of MRI, endorectal ultrasonography (ERUS), and computed tomography (CT) in predicting the response of locally advanced rectal cancer after preoperative therapy.

METHODS

All previously published articles on the role of MRI, CT, and/or ERUS in predicting the response of rectal cancer to preoperative therapy were collected. We divided the objective in 3 parts: the accuracy to assess (i) complete response, (ii) to detect T4 tumors with invasion to the circumferential resection margin (CRM), and (iii) to predict the presence of lymph node metastasis. The pooled estimates of, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated using a bivariate mixed effect analysis.

RESULTS

Forty-six studies comprising 2,224 patients were included. (i) The pooled accuracy to assess complete tumor response were (a) 75% for MRI, (b) 82% for ERUS, (c) and 83% for CT. (ii) Pooled accuracy to detect T4 tumors with invasion to the CRM were (a) 88% and (b) 94% for ERUS. (iii) Pooled accuracy to predict the presence of lymph node metastasis was (a) 72% for MRI, (b) 72% for ERUS, (c) and 65% for CT.

CONCLUSION

MRI, CT, and ERUS cannot be used to predict complete response of locally advanced rectal cancer after CRT. In addition, the positive predictive value for these imaging techniques is low for the assessment of tumor invasion in the CRM. The accuracy of the modalities to predict the presence of metastatic lymph node disease is also low.

Assessing pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: a systematic review

AIM

Pathological complete response to neoadjuvant chemoradiotherapy is found in 20% of patients with rectal cancer undergoing long-course chemoradiotherapy. Some authors have suggested that these patients do not need to undergo surgery and can be managed with careful follow-up, with surgery only used in the event of clinical failure. Widespread adoption of this regimen is limited by the accuracy of methods to confirm a pathological complete response (pCR).

METHOD

A systematic search of PubMed, Medline and Cochrane databases was conducted to identify clinical, histological and radiological features in those patients with rectal cancer who achieved a pCR following chemoradiotherapy. Searches were conducted with the following keywords and MeSH search terms: 'rectal neoplasm', 'response', 'neoadjuvant', 'preoperative chemoradiation' and 'tumour response'. After review of title and abstracts, 89 articles addressing the assessment of pCR were identified.

RESULTS

Histology and clinical assessment are the most effective methods of assessment of pCR, with histology considered the gold standard. Clinical assessment is limited to low rectal tumours and is open to significant inter-rater variability, while histological examination requires a surgical specimen. Diffusion-weighted MRI and (18) F-fluorodeoxyglucose positron emission tomography/CT demonstrate the greatest potential for the assessment of pCR, but both modalities have limited accuracy.

CONCLUSION

Determination of a pCR is crucial if a nonoperative approach is to be undertaken proactively. Various methods are available, but currently they lack sufficient sensitivity and specificity to define management. This is likely to be an area of further research in the future.

Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy

AIM

Restaging imaging by MRI or endorectal ultrasound (ERUS) following neoadjuvant chemoradiotherapy is not routinely performed, but the assessment of response is becoming increasingly important to facilitate individualization of management.

METHOD

A search of the MEDLINE and Scopus databases was performed for studies that evaluated the accuracy of restaging of rectal cancer following neoadjuvant chemoradiotherapy with MRI or ERUS against the histopathological outcome. A systematic review of selected studies was performed. The methodological quality of studies that qualified for meta-analysis was critically assessed to identify studies suitable for inclusion in the meta-analysis.

RESULTS

Sixty-three articles were included in the systematic review. Twelve restaging MRI studies and 18 restaging ERUS studies were eligible for meta-analysis of T-stage restaging accuracy. Overall, ERUS T-stage restaging accuracy (mean [95% CI]: 65% [56-72%]) was nonsignificantly higher than MRI T-stage accuracy (52% [44-59%]). Restaging MRI is accurate at excluding circumferential resection margin involvement. Restaging MRI and ERUS were equivalent for prediction of nodal status: the accuracy of both investigations was 72% with over-staging and under-staging occurring in 10-15%.

CONCLUSION

The heterogeneity amongst restaging studies is high, limiting conclusive findings regarding their accuracies. The accuracy of restaging imaging is different for different pathological T stages and highest for T3 tumours. Morphological assessment of T- or N-stage by MRI or ERUS is currently not accurate or consistent enough for clinical application. Restaging MRI appears to have a role in excluding circumferential resection margin involvement.

Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer

The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.

Multidisciplinary treatment of rectal cancer in 2014: where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.

[The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders]

Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We recommend this article to gastroenterologists, surgeons, internists, pulmonologists, and to specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society.

Restaging of locally advanced rectal cancer with magnetic resonance imaging and endoluminal ultrasound after preoperative chemoradiotherapy: a systemic review and meta-analysis

BACKGROUND

Magnetic resonance imaging and endoluminal ultrasound play an important role in the restaging of locally advanced rectal cancer after preoperative chemoradiotherapy, yet their diagnostic accuracy is still controversial.

OBJECTIVE

Meta-analysis was performed to estimate the diagnostic performance of MRI and endoluminal ultrasound.

DATA SOURCES

Electronic databases from 1996 to March 2012 were searched.

STUDY SELECTION AND INTERVENTIONS

Either MRI or endoluminal ultrasound was used to restage rectal cancer after chemoradiotherapy or radiation.

MAIN OUTCOME MEASURES

T category, lymph node, and circumferential resection involvement were measured.

RESULTS

The sensitivity estimate for rectal cancer diagnosis (T0) by endoluminal ultrasound (37.0%; 95% CI, 24.0%-52.1%) was higher (p = 0.04) than the sensitivity estimate for MRI (15.3%; 95% CI, 6.5%-32.0%). For T3-4 category, sensitivity estimates of MRI and endoluminal ultrasound were comparable, 82.1% and 87.6%, whereas specificity estimates were poor (53.5% and 66.4%). For lymph node involvement, there was no significant difference between the sensitivity estimates for MRI (61.8%) and endoluminal ultrasound (49.8%). Specificity estimates for MRI and endoluminal ultrasound were 72.0% and 78.7%. For circumferential resection margin involvement, MRI sensitivity and specificity were 85.4% and 80.0%.

LIMITATIONS

To identify the heterogeneity, metaregression was performed on covariates. However, few of the covariates were identified to be statistically significant because of the lack of adequate original data.

CONCLUSION

Accurate restaging of locally advanced rectal cancer by MRI and endoluminal ultrasound is still a challenge. Identifying T0 rectal cancer by imaging is not reliable. Before performing surgery, restaging is important, but some of the T0-2 patients are likely overestimated as T3-4. Both modalities for lymph node involvement are not very good. Magnetic resonance imaging may be a good method to reassess circumferential resection margin.

Current approaches and challenges for monitoring treatment response in colon and rectal cancer

Introduction: With the advent of multidisciplinary and multimodality approaches to the management of colorectal cancer patients, there is an increasing need to define how we monitor response to novel therapies in these patients. Several factors ranging from the type of therapy used to the intrinsic biology of the tumor play a role in tumor response. All of these can aid in determining the ideal course of treatment, and may fluctuate over time, pending down-staging or progression of disease. Therefore, monitoring how disease responds to therapy requires standardization in order to ultimately optimize patient outcomes. Unfortunately, how best to do this remains a topic of debate among oncologists, pathologists, and colorectal surgeons. There may not be one single best approach. The goal of the present article is to shed some light on current approaches and challenges to monitoring treatment response for colorectal cancer.

Methods: A literature search was conducted utilizing PubMed and the OVID library. Key-word combinations included colorectal cancer metastases, neoadjuvant therapy, rectal cancer, imaging modalities, CEA, down-staging, tumor response, and biomarkers. Directed searches of the embedded references from the primary articles were also performed in selected circumstances.

Results: Pathologic examination of the post-treatment surgical specimen is the gold standard for monitoring response to therapy. Endoscopy is useful for evaluating local recurrence, but not in assessing tumor response outside of the limited information gained by direct examination of intra-lumenal lesions. Imaging is used to monitor tumors throughout the body for response, with CT, PET, and MRI employed in different circumstances. Overall, each has been validated in the monitoring of patients with colorectal cancer and residual tumors.

Conclusion: Although there is no imaging or serum test to precisely correlate with a tumor's response to chemo- or radiation therapy, these modalities, when used in combination, can aid in allowing clinicians to adjust medical therapy, pursue operative intervention, or (in select cases) identify complete responders. Improvements are needed, however, as advances across multiple modalities could allow appropriate selection of patients for a close surveillance regimen in the absence of operative intervention.

Value of transrectal ultrasonography for tumor node metastasis restaging in patients with locally advanced rectal cancer after neoadjuvant chemoradiotherapy

OBJECTIVE

To explore the value of transrectal ultrasonography (TRUS) for tumor node metastasis (TNM) restaging for patients with locally advanced rectal cancer after neoadjuvant chemoradiotherapy (neo-CRT).

METHODS

One hundred and forty-nine patients with locally advanced rectal cancer (cT3-4 or cN+) who underwent TRUS after neo-CRT were retrospectively reviewed. TRUS restaging was compared with the results of post-operative pathological TNM findings.

RESULTS

After neo-CRT, the accuracy of TRUS for diagnosing T-staging was 30.9%, with 60.4% (90/149) of cases overestimated. The sensitivity of TRUS for T-staging (T0 vs T1 vs T2 vs T3 vs T4) were 16.3%, 0%, 12.5%, 42.6% and 75.0%, respectively. The accuracy of TRUS for diagnosing N-staging after neo-CRT was 81.2%, with the sensitivities of N0 and N+ were 93.3% and 31.0%, respectively. After neo-CRT, 27.5% (41/149) of patients achieved pathologically complete response (pCR). The sensitivity, specificity, positive predictive value and negative predictive values of TRUS for pCR were 17.1%, 99.1%, 87.5% and 75.9%, respectively.

CONCLUSIONS

TRUS can be applied for restaging T4 and N0, and has potential for screening out patients with pCR in those with locally advanced rectal cancer after neo-CRT, although some stages are overestimated for T-staging and its sensitivity for predicting pCR is low.

Endoscopic ultrasound-guided fine needle aspiration as a diagnostic and staging tool for rectal and perirectal lesions-an institutional experience

The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in evaluating lesions adjacent to the upper gastrointestinal tract wall is well established. However, this tool is underused in evaluating rectal and perirectal lesions, possibly due to insufficient experience and underrecognized value of this procedure. In this study, we report our institutional experience with EUS-FNA as a diagnostic and staging tool for rectal and perirectal lesions. A retrospective chart review was performed and a cohort of 38 patients who underwent rectal EUS-FNA (41 specimens) at our institution between January 2002 and July 2012 was retrieved. The cytology diagnoses were compared with the concurrent or follow-up histologic and clinical diagnoses. Among the total 41 cases, rectal EUS-FNA was performed as a diagnostic procedure in 22 (54%) and a staging procedure in 19 (46%) cases. On cytology examination, 18 cases (44%) were diagnosed as malignant; 1 (2%), as atypical/suspicious for malignancy; 3 (7%), as benign neoplastic; 13 (32%), as nonneoplastic; and 6 (15%), as nondiagnostic cases. Concurrent or follow-up histologic diagnoses were available in 20 cases (48%), 19 of them had concordant cytological/histologic findings (10 benign, 9 malignant). One perirectal lymph node with negative cytology diagnosis was found to be positive on histologic examination, probably due to sampling error on cytology. The sensitivity and specificity of EUS-FNA for detecting malignant rectal/perirectal lesions in this study were 91% and 100%, respectively. Endoscopic ultrasound-guided fine needle aspiration is a useful diagnostic tool for rectal/perirectal lesions; it confirms or excludes malignancy for lesions with high or low clinical suspicions. It serves as a reliable staging method to identify patients for proper clinical management.

[The role of endoscopic ultrasonography in the diagnosis of rectal cancers]

INTRODUCTION

The exact extent of rectal cancer and regional lymph node involvement are essential for providing the optimal treatment.

AIM

The aim of the authors was to evaluate the diagnostic accuracy of endoscopic ultrasonography in routine clinical staging of rectal cancer.

METHOD

Outcomes of endoscopic ultrasonography performed between 2006 and 2012 for rectal cancer staging were retrospectively analyzed. The correlation between the endoscopic and pathological stages was evaluated.

RESULTS

In patients without neoadjuvant chemotherapy the sensitivity (75% and 73%) and specificity (74% and 80%) of endoscopic ultrasonography for differentiating T1 and T2 stages (respectively) were high, however, it was significantly decreased in differentiation of T3 stage (58%). A weak association was found in different N stages (45-62%). The diagnostic accuracy of endoscopic ultrasound was reduced significantly after the oncological treatment due to the overevaluation (27%) of the findings. After a relatively short learning curve (30 examinations) high correlation was detected between pT and uT stages.

CONCLUSIONS

Endoscopic ultrasonography provides great help in staging early rectal cancers. Due to the lower sensitivity in patients receiving neoadjuvant therapy, it is not a useful tool after down-staging.

Organ-preserving therapy for rectal cancer

SUMMARY Total mesorectal excision has resulted in low local recurrence rates in rectal cancer patients; however, it is associated with a significant impairment in quality of life. The operation may be disfiguring and cause permanent effects on gastrointestinal, genitourinary and sexual function. Recently, researchers have identified subgroups of rectal cancer patients who may be able to forgo total mesorectal excision without compromising their oncological outcomes. Two groups of patients are candidates for organ preservation: those with early-stage disease that may be adequately addressed by a more limited resection, and those with locally advanced disease that has responded completely to neoadjuvant therapy. Additionally, radiation alone may be curative in both early and locally advanced disease. This article reviews the data regarding these approaches.

[Rectal cancer - local staging and imaging under neoadjuvant therapy]

CLINICAL/METHODICAL ISSUE

Rectal cancer restaging after neoadjuvant therapy is based on two principles: an anatomic definition of the tumor allowing surgical planning and prognostic stage grouping.

STANDARD RADIOLOGICAL METHODS

Emerging data suggest that reassessment using a combination of different imaging modalities may help to provide valuable prognostic information before definitive surgery.

METHODICAL INNOVATIONS

Perfusion computed tomography (CT) may provide special information regarding tumor vascularity.

PERFORMANCE

Evaluation of therapy response, especially of the circumferential resection margin (CRM) is necessary for surgical planning.

ACHIEVEMENTS

For local staging high-resolution and diffusion-weighted magnetic resonance imaging has proven to be of high diagnostic accuracy.

PRACTICAL RECOMMENDATIONS

The M status should be assessed using multidetector computed tomography (MDCT) according to response evaluation criteria in solid tumors (RECIST) while lymph node evaluation requires either magnetic resonance imaging or positron emission tomography/computed tomography scanning.

Lymph node retrieval after preoperative chemoradiotherapy for rectal cancer

BACKGROUND

Current guidelines recommend the assessment of at least 12 lymph nodes for rectal cancer staging. Preoperative chemoradiotherapy may affect lymph node yield in this malignancy. This study investigated the impact of neoadjuvant chemoradiotherapy on the number of lymph nodes retrieved from rectal cancer patients.

METHODS

An analysis of 162 rectal cancer patients who underwent curative surgery between 2005 and 2010. Seventy-one patients with stage II or III tumors received preoperative chemoradiotherapy. Using multivariate analysis, we assessed the correlation between clinicopathologic variables and number of retrieved lymph nodes. We also evaluated the association between survival and number of lymph nodes obtained.

RESULTS

On multivariate analysis, preoperative chemoradiotherapy was the only variable to independently affect the number of lymph nodes obtained. The mean number of lymph nodes was 14.2 in patients treated with preoperative chemoradiotherapy and 19.4 in those not treated (P < 0.001). In the chemoradiotherapy group, 29.6 % of patients had fewer than 12 lymph nodes obtained compared with 9.9 % in the primary surgery group (P = 0.003). After chemoradiation, the number of retrieved lymph nodes was inversely correlated with tumor regression grade. Results showed that 5-year overall and disease-free survival were similar whether the patient had 12 or more nodes retrieved or not.

CONCLUSIONS

Preoperative chemoradiotherapy reduces the lymph node yield in rectal cancer. The number of retrieved lymph nodes is affected by degree of histopathologic response of the tumor to chemoradiation. Thus, number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection after neoadjuvant chemoradiotherapy for rectal cancer.

Prediction in rectal cancer

The treatment of rectal cancer largely depends on disease stage at diagnosis, based on which patients can be classified as low, intermediate, or high risk. Prognostic and predictive markers, specific to each risk category, can be applied for optimal risk classification and subsequent treatment allocation. These markers are either histopathological, determined with imaging, or have a biomolecular background. This review provides an overview of the current status of treatment options and the use of prognostic and predictive markers in each risk category. An effort was made to identify those markers that are currently lacking in, but have the potential to improve, the clinical decision process by discussing the data from recent studies aimed at the development of new prognostic and predictive markers. At this moment, none of the markers studied has been proven to be of significant, independent value, justifying implementation in daily clinical practice. However, recent developments in imaging techniques and biomolecular research do show great potential.

Accuracy of endoscopic ultrasound in staging and restaging patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiation

BACKGROUND

To date, the role of endoscopic ultrasound (EUS) in restaging locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (NAT) have not been thoroughly investigated.

AIM

To evaluate accuracy and clinical usefulness of EUS for both staging and restaging LARC.

METHODS

According to EUS staging, patients with LARC were enrolled in the study. Those who underwent surgery directly represented a control group useful for evaluating the accuracy of EUS in staging LARC. In the study group, EUS was repeated seven weeks after NAT, before surgery. The results of EUS were compared with the corresponding pTN stages.

RESULTS

From 2000 to 2006, 212 consecutive patients with RC underwent EUS staging. Among them EUS diagnosed 162 LARC (M/F = 93/69; mean age: 60 years [range 40-80]). The final study group included 85 patients with LARC. EUS restaging had an overall accuracy of 61% and 59% for T and N-stage, respectively. In the control group, the accuracy of EUS in staging LARC was 86% and 58% for T and N-stage, respectively.

CONCLUSION

EUS accurately stages LARC and enables appropriate decision-making, with selection of those patients who need NAT. On the other hand, EUS restaging of LARC after NAT has low accuracy and should not be used in clinical practice.

EUS-FNA assessment of extramesenteric lymph node status in primary rectal cancer

BACKGROUND

Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer. The accuracy of imaging alone with CT, magnetic resonance imaging, or rigid endorectal US is poor. The addition of EUS-FNA may enhance extramesenteric lymph node metastases detection (M1 disease) and overall staging accuracy.

OBJECTIVE

To evaluate the frequency of extramesenteric lymph node visualization by EUS and the rate of extramesenteric lymph node metastases by FNA. Secondary goals were to evaluate the clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases, disease progression, and overall mortality.

DESIGN

Retrospective cohort study.

SETTINGS

Tertiary referral center.

RESULTS

Forty-one of 316 patients (13%) with primary rectal cancer over a 6-year period had M1 disease by EUS-FNA. Significant clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases included the serum carcinoembryonic antigen level, tumor length 4 cm and longer, annularity 50% or more, sessile morphology, and lymph node size. The sensitivity and specificity of CT for extramesenteric lymph node metastases were 44% and 89%, respectively. Twenty-three of 316 rectal cancer endosonographic procedures (7.3%) were up-staged by FNA, which established extramesenteric lymph node metastases. Over a 4-year follow-up, disease progression and overall mortality of patients with extramesenteric lymph node metastases was observed in 6 patients (14.6%) and 14 patients (34%), respectively.

CONCLUSIONS

Preoperative EUS-FNA identification of extramesenteric lymph node metastases outside of standard radiation fields or total mesorectal excision resection margins could affect medical and surgical planning.

Utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of colorectal carcinoma

The objective of this study is to assess the utility of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the diagnosis and staging of colorectal cancer. The study includes patients who underwent EUS-FNA at our institution for staging of colorectal carcinoma or for evaluation peri-rectal masses or distal metastases from August 2000 to November 2010. We assessed the frequency with which EUS-FNA procedure confirms the diagnosis of malignancy and the percent of cases in which it modifies staging of colorectal carcinoma. Using histology as a reference standard, we also assessed the diagnostic performance. We identified 79 cases of EUS-FNA from 77 patients, mean (SD) age of 60 (12.5), 44 males. Twenty-seven (34%) aspirates were from patients with primary rectal/peri-rectal masses, 15 (19%) were from patients with suspected regional lymph node metastasis, and 37 (47%) were cases of suspected of distal metastasis. All lesions were clinically suspicious for primary or metastatic colorectal carcinoma. On cytologic examinations, 43 (54%) cases were confirmed as malignant, 6 (8%) were benign neoplasms, 4 (5%) were suspicious for malignant neoplasm, 2 (3%) showed atypical cells, and the rest 24 (30%) were negative for neoplasms. Fourteen of 27 (52%) of the local rectal masses were confirmed as colorectal carcinoma. Eleven of 15 (73%) regional lymph nodes were positive for metastasis-all, but two of these metastases, were of colorectal origin. Twenty of 37(54%) distal lesions were metastatic neoplasms and 15 of those were colorectal in origin. Diagnosis of primary colorectal carcinoma was confirmed in 52% of the clinically suspicious primary lesions and in 42% regional or distal metastatic lesions. Using histology as a reference standard in 27 of 79 (29%) cases, we calculated an overall sensitivity, specificity, and positive and negative predictive values (C.I) of EUS-FNA of 89% (74-100%), 79% (50-100%) 89% (74-100%), and 79% (51-100%). EUS-FNA is useful for assessing primary and metastatic colorectal lesion. This technique improves staging of suspected nodal or distant metastases.

Accuracy of endoscopic ultrasound to assess tumor response after neoadjuvant treatment in rectal cancer: can we trust the findings?

BACKGROUND

The finding that some rectal cancers respond to neoadjuvant chemoradiation is broadening new surgical options for the treatment of some of these tumors that, until now, required a total mesorectal excision. Nevertheless, a fine match between clinical and pathological response is required when planning conservative surgical approaches.

OBJECTIVE

This study aims to prospectively validate the use of endoscopic ultrasound as a predictor of clinical and pathological tumor response in patients with locally advanced rectal cancer.

DESIGN

: This is an observational study of a cohort of patients undergoing chemoradiation followed by surgery.

SETTINGS

This study was conducted at a tertiary medical center.

PATIENTS

A total of 235 consecutive patients who underwent chemoradiation followed by surgery at a single institution during a 7-year period were included.

MAIN OUTCOME MEASURES

All tumors were staged and restaged at 4 to 6 weeks after neoadjuvant treatment. Downsizing and downstaging were calculated between the initial and posttreatment measures and correlated to the pathological stage. The accuracy of endoscopic ultrasound to predict response was determined.

RESULTS

Findings after chemoradiation showed T-downstaging in 54 patients (23%) and N-downstaging in 110 (47%). Overstaging occurred in 88 (37%) patients and was more commonly observed than understaging (21 patients; 9%). Related to the pathological report, endoscopic ultrasound correctly matched the T stage in 54% and the N stage in 75% of tumors. Sensitivity, specificity, and positive and negative predictive values to predict nodal involvement were 39%, 91%, 67%, and 76%. Accuracy was not influenced by such factors as age, distance of the tumor from the anal verge, or time to surgery.

LIMITATIONS

This study was limited by the lack of comparison with other imaging methods.

CONCLUSIONS

Endoscopic ultrasound allows prediction of involved lymph nodes in 75% of the cases; however, 1 in 5 patients are missclassified as uN0 after neoadjuvant treatment. In our point of view, this percentage is too high to rely only on this diagnostic modality to support a "wait and see" approach.

Application of endoscopic sonography in preoperative staging of rectal cancer: six-year experience

OBJECTIVES

The aim of this study was to evaluate our experience with the application of endoscopic sonography in preoperative staging of rectal cancer.

METHODS

Between April 2004 and May 2010, 192 patients with rectal cancer first underwent endoscopic sonography and then underwent surgery at our hospital. None of the patients in this study received neoadjuvant therapy. The endoscopic sonographic staging results were compared with those of postoperative pathologic staging.

RESULTS

The accuracy of overall T staging was 86.5%, and for T1, T2, T3, and T4, the accuracy rates were 86.7%, 94.0%, 86.2%, and 65.5%, respectively. The accuracy of T staging for ulcerated lesions was significantly lower than that for nonulcerated lesions (P = .013). The accuracy of T staging between nontraversable stenotic lesions and traversable lesions was also significantly different (P = .002). The accuracy of N staging was 77.8%, and the specificity and sensitivity were 85.6% and 74.2%, respectively.

CONCLUSIONS

Endoscopic sonography is safe and effective for preoperative staging of rectal cancer and should be a routine examination before surgery. As for ulcerated and nontraversable stenotic lesions, however, the results of endoscopic sonographic staging could be doubtful. Moreover, the accuracy of endoscopic sonographic N staging still needs modification by further research.

Linear array ultrasonography to stage rectal neoplasias suitable for local treatment

BACKGROUND

Because of the many therapeutic options available, a reliable staging is crucial for rectal neoplasia management. Adenomas and cancers limited to the submucosa without lymph node involvement may be treated locally.

AIMS

The aim of this study is to evaluate the diagnostic accuracy of endorectal ultrasonography in the staging of neoplasias suitable for local treatment.

METHODS

We considered all patients who underwent endorectal ultrasonography between 2001 and 2010. The study population consisted of 92 patients with 92 neoplasias (68 adenocarcinomas and 24 adenomas). A 5 and 7.5MHz linear array echoendoscope was used. The postoperative histopathologic result was compared with the preoperative staging defined by endorectal ultrasonography. Adenomas and cancers limited to the submucosa were considered together (pT0-1).

RESULTS

The sensitivity, specificity, overall accuracy rate, positive predictive value, and negative predictive value of endorectal ultrasonography for pT0-1 were 86%, 95.6%, 91.3%, 94.9% and 88.7%. Those for nodal involvement were 45.4%, 95.5%, 83%, 76.9% and 84%, with 3 false positive results and 12 false negative. For combined pT0-1 and pN0, endorectal ultrasonography showed an 87.5% sensitivity, 95.9% specificity, 92% overall accuracy rate, 94.9% positive predictive value and 90.2% negative predictive value.

CONCLUSION

Endorectal linear array ultrasonography is a reliable tool to detect rectal neoplasias suitable for local treatment.

Does a learning curve exist in endorectal two-dimensional ultrasound accuracy?

BACKGROUND

Aim of the study was to assess adequacy of Colorectal Surgical Society of Australia and New Zealand (CSSANZ) endorectal ultrasound (ERUS) training and whether a subsequent learning curve exists.

METHODS

A prospective audit of ERUS for staging rectal cancer by a single surgeon from commencement of consultant practice was performed. Data were recorded in a prospectively maintained database. The audit commenced on completion of CSSANZ training. T- and N-stage were assessed clinically, then by ERUS prior to treatment and finally by histology over 8 years.

RESULTS

The results were compared over three time periods: the first a single year, then two three-year periods. Two hundred and seventy-two patients were examined. Two hundred and thirty-three were assessable for T-stage (13 no tumour excision, 26 long course pre-operative radiotherapy) and 142 for N-stage (74 endoanal excision, 17 proximal mesorectum un-assessable). Overall accuracy was 82% for T-stage and 73% for N-stage. Accuracy for T- and N-staging did not change significantly over the three time periods (T: 82.1, 82.3, 81.6%, P = 0.14; N: 83.3, 67.9, 74.2%, P = 0.31). The utility of ERUS was demonstrated by clinical assessment not being possible in 32% of cases and where the two modalities disagreed was correct 82% of the time.

CONCLUSIONS

Endorectal ultrasound rectal cancer staging is accurate for T-stage. Competency in ERUS can be achieved in the CSSANZ fellowship and accuracy does not improve with further experience. An ERUS accreditation scheme should be established for future trainees.

Current trends in staging rectal cancer

Management of rectal cancer has evolved over the years. In this condition preoperative investigations assist in deciding the optimal treatment. The relation of the tumor edge to the circumferential margin (CRM) is an important factor in deciding the need for neoadjuvant treatment and determines the prognosis. Those with threatened or involved margins are offered long course chemoradiation to enable R₀ surgical resection. Endoanal ultrasound (EUS) is useful for tumor (T) staging; hence EUS is a useful imaging modality for early rectal cancer. Magnetic resonance imaging (MRI) is useful for assessing the mesorectum and the mesorectal fascia which has useful prognostic significance and for early identification of local recurrence. Computerized tomography (CT) of the chest, abdomen and pelvis is used to rule out distant metastasis. Identification of the malignant nodes using EUS, CT and MRI is based on the size, morphology and internal characteristics but has drawbacks. Most of the common imaging techniques are suboptimal for imaging following chemoradiation as they struggle to differentiate fibrotic changes and tumor. In this situation, EUS and MRI may provide complementary information to decide further treatment. Functional imaging using positron emission tomography (PET) is useful, particularly PET/CT fusion scans to identify areas of the functionally hot spots. In the current state, imaging has enabled the multidisciplinary team of surgeons, oncologists, radiologists and pathologists to decide on the patient centered management of rectal cancer. In future, functional imaging may play an active role in identifying patients with lymph node metastasis and those with residual and recurrent disease following neoadjuvant chemoradiotherapy.

18Fluoro-deoxy-glucose positron emission tomography in assessing tumor response to preoperative chemoradiation therapy for locally advanced rectal cancer

BACKGROUND

This study aims to evaluate the efficacy of (18)F-FDG PET in assessing tumor response after preoperative chemoradiation therapy (CRT) for rectal cancer.

METHODS

Maximum standardized uptake value (SUV) was measured for 37 patients who underwent (18)F-FDG PET before and 4 weeks after completion of preoperative CRT. Pre-SUV, post-SUV, the difference between pre- and post-SUV (ΔSUV), and reduction rate (RR) were correlated with tumor response.

RESULTS

A lower mean post-SUV and a higher mean RR were shown in good tumor response (T-downstaging(+) and tumor regression grade 1, 2). Considering pathologic complete response (pCR), the mean post-SUV and the mean RR were significantly different between pCR (+) patients (N = 13) and pCR (-) patients (N = 24) (2.7 vs. 4.8, P < 0.001, 73.9% vs. 58.7%, P = 0.009). With a 3.35 cut-off value for the post-SUV by receiver operating characteristic analysis, 84.6% sensitivity, 79.2% specificity, and 81.2% overall accuracy were obtained for discriminating between pCR (+) and pCR (-) (area under the curve = 0.885, P < 0.001).

CONCLUSIONS

(18)F-FDG PET is potentially useful as a method for assessing tumor response after preoperative CRT for rectal cancer. Post-SUV and RR were significantly associated with pathological treatment response, especially in pCR.

Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review

BACKGROUND

Rectal cancers that are confined to the mucosa (T0) can be resected endoscopically. This can help the patient avoid transabdominal surgery. The published data on accuracy of endoscopic ultrasound (EUS) to predict T0 stage of rectal cancers has been varied.

AIM

To evaluate the accuracy of EUS in T0 staging of rectal cancers. METHOD (STUDY SELECTION CRITERIA): Only EUS studies confirmed by surgery were selected. T0 was defined as tumor confined to the mucosa. DATA COLLECTION AND EXTRACTION: Articles were searched in Medline, PubMed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both the fixed-effects model and random-effects model.

RESULTS

An initial search identified 3,360 reference articles. Of these, 339 relevant articles were selected and reviewed. Eleven studies (N = 1,791) which met the inclusion criteria were included in this analysis. Pooled sensitivity of EUS in diagnosing T0 was 97.3% (95% CI: 93.7-99.1). EUS had a pooled specificity of 96.3% (95% CI: 95.3-97.2). The positive likelihood ratio of EUS was 21.9 (95% CI: 16.3-29.7) and negative likelihood ratio was 0.08 (95% CI: 0.04-0.15). All the pooled estimates, calculated by fixed and random effect models, were similar. The P-value for Chi-squared heterogeneity for all the pooled accuracy estimates was >0.10.

CONCLUSIONS

EUS has excellent sensitivity and specificity, this helps accurately diagnose T0 stage of rectal cancers. Over the past two decades, the sensitivity and specificity of EUS to diagnose T0 stage of rectal cancers has remained high. This can help physicians offer endoscopic treatment to these patients, therefore EUS should be strongly considered for staging of early rectal cancers.

How useful is rectal endosonography in the staging of rectal cancer?

It is essential in treating rectal cancer to have adequate preoperative imaging, as accurate staging can influence the management strategy, type of resection, and candidacy for neoadjuvant therapy. In the last twenty years, endorectal ultrasound (ERUS) has become the primary method for locoregional staging of rectal cancer. ERUS is the most accurate modality for assessing local depth of invasion of rectal carcinoma into the rectal wall layers (T stage). Lower accuracy for T2 tumors is commonly reported, which could lead to sonographic overstaging of T3 tumors following preoperative therapy. Unfortunately, ERUS is not as good for predicting nodal metastases as it is for tumor depth, which could be related to the unclear definition of nodal metastases. The use of multiple criteria might improve accuracy. Failure to evaluate nodal status could lead to inadequate surgical resection. ERUS can accurately distinguish early cancers from advanced ones, with a high detection rate of residual carcinoma in the rectal wall. ERUS is also useful for detection of local recurrence at the anastomosis site, which might require fine-needle aspiration of the tissue. Overstaging is more frequent than understaging, mostly due to inflammatory changes. Limitations of ERUS are operator and experience dependency, limited tolerance of patients, and limited range of depth of the transducer. The ERUS technique requires a learning curve for orientation and identification of images and planes. With sufficient time and effort, quality and accuracy of the ERUS procedure could be improved.

Endoscopic ultrasound and magnetic resonance imaging for re-staging rectal cancer after radiotherapy

AIM

To compare the sensitivity and specificity of two imaging techniques, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI), in patients with rectal cancer after neoadjuvant chemoradiation therapy. And we compared EUS and MRI data with histological findings from surgical specimens.

METHODS

Thirty-nine consecutive patients (51.3% Male; mean age: 68.2 +/- 8.9 years) with histologically confirmed distal rectal cancer were examined for staging. All patients underwent EUS and MRI imaging before and after neoadjuvant chemoradiation therapy.

RESULTS

After neoadjuvant chemoradiation, EUS and MRI correctly classified 46% (18/39) and 44% (17/39) of patients, respectively, in line with their histological T stage (P > 0.05). These proportions were higher for both techniques when nodal involvement was considered: 69% (27/39) and 62% (24/39). When patients were sorted into T and N subgroups, the diagnostic accuracy of EUS was better than MRI for patients with T0-T2 (44% vs 33%, P > 0.05) and N0 disease (87% vs 52%, P = 0.013). However, MRI was more accurate than EUS in T and N staging for patients with more advanced disease after radiotherapy, though these differences did not reach statistical significance.

CONCLUSION

EUS and MRI are accurate imaging techniques for staging rectal cancer. However, after neoadjuvant RT-CT, the role of both methods in the assessment of residual rectal tumors remains uncertain.

Endosonographic staging of lower intestinal malignancy

The use of EUS in the assessment of rectal pathology is well established. The accurate staging of lower intestinal tumours predicts prognosis and guides the planning of individual patient treatment. Increased experience and the development of high resolution three-dimensional EUS has lead to the greater accuracy of rectal staging with EUS of rectal tumours now considered the gold standard showing T stage accuracy that ranges from 75% to 95%, with N stage accuracy ranging from 65% to 80%. The use of EUS in the staging of colonic pathology, however, is not so well established though advances in miniprobe EUS has improved the assessment of colonic tumours. EUS is also of benefit in the assessment of anal pathology though here, accurate correlation with histology has not been firmly established.

Preoperative staging of rectal cancer

Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography–computed tomography, with respect to local and distant disease.

A new rectal ultrasonographic method for the staging of rectal cancer

PURPOSE

Radial transrectal ultrasound is the most frequently used method for preoperative staging of rectal cancer. Accuracy rates of transrectal ultrasound have fallen significantly to 64% and 70% for tumor and node staging, respectively. The use of a frontal probe may overcome the drawbacks of radial transrectal ultrasound. This study was designed to compare the accuracy of frontal transrectal ultrasound performed with a frontal probe with the classic procedure, which uses a radial probe, in the preoperative T and N staging of rectal cancer.

METHODS

Seventy-four patients with rectal adenocarcinoma underwent both techniques. Thirty patients had a neoadjuvant treatment. The staging accuracy of both methods was determined by comparing the results of each with the findings of surgical histopathologic evaluation.

RESULTS

Forty-six men and 28 women were recruited. Frontal transrectal ultrasound was performed in all patients. Staging was amenable in only 58 patients with the radial transrectal ultrasound because the tumors were either stenotic or too proximal. Frontal transrectal ultrasound was accurate in the T staging of 89% of the tumors, whereas radial transrectal ultrasound was accurate in only 69% (P = 0.004). The difference was even more significant when we compared accuracy among the 58 patients in whom both examinations were completed (P = 0.002). Both methods had similar accuracy for lymph node staging. Neoadjuvant treatment had no influence on accuracy. No overstaging of the tumor occurred with the frontal transrectal ultrasound. Understaging was more frequently encountered with radial transrectal ultrasound than with frontal transrectal ultrasound (26% vs. 11%, respectively; P = 0.036).

CONCLUSION

Compared with radial transrectal ultrasound, frontal transrectal ultrasound has a better accuracy for T staging of rectal cancer. Its advantage in overcoming the drawbacks of radial transrectal ultrasound may make this procedure the method of choice for rectal cancer staging.

Prospective assessment of EUS criteria for lymphadenopathy associated with rectal cancer

BACKGROUND

There are few data that assess the accuracy of echo characteristics for predicting lymph-node (LN) metastases in patients with rectal cancer.

OBJECTIVE

To identify nodal echo characteristics and size predictive of malignant infiltration and to determine if any combination of standard nodal criteria has sufficient predictive value to preclude FNA.

DESIGN

Prospective uncontrolled study.

SETTING

Tertiary-referral hospital.

PATIENTS

Seventy-six patients (68% men) with untreated rectal cancer; 52 had visualized LNs.

INTERVENTION

EUS-guided FNA.

MAIN OUTCOME MEASUREMENTS

Evaluation of perirectal nodal morphology accuracy that corresponds to malignant cytology and identification of echo criteria, including LN size, to have sufficient predictive value to predict malignancy.

RESULTS

Forty-three of 52 patients (83%) underwent FNA of a visualized LN. Nodal hypoechogenicity and short-axis length >or=5 mm were factors independently predictive of malignancy. The number of malignant nodal echo features per node did not distinguish benign from malignant pathology, except when all 4 features were present. Only 68% of malignant LN had >or=3 echo characteristics. An optimum LN short-axis or long-axis length cutoff value of 6 mm or 9 mm were 90% and 95% specific, respectively, for the presence of malignancy by receiver operating characteristic analysis.

LIMITATIONS

FNA was performed in a subset of identified LNs.

CONCLUSIONS

Nodal echo features alone are often inadequate to establish the presence of locoregional metastatic disease by EUS. These data support the value of FNA to confirm the presence of malignancy in place of relying on imaging criteria.

Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review

BACKGROUND

Nodal staging in patients with rectal cancer predicts prognosis and directs therapy. Published data on the accuracy of endoscopic ultrasound (EUS) for diagnosing nodal invasion in patients with rectal cancer has been inconsistent.

AIM

To evaluate the accuracy of EUS in diagnosing nodal metastasis of rectal cancers.

METHOD

Study Selection Criteria: Only EUS studies confirmed by surgical histology were selected. Data Collection and Extraction: Articles were searched in Medline, Pubmed, and CENTRAL.

STATISTICAL METHOD

Pooling was conducted by both fixed-effects model and random-effects model.

RESULTS

The initial search identified 3610 reference articles in which 352 relevant articles were selected and reviewed. Data were extracted from 35 studies (N = 2732) that met the inclusion criteria. Pooled sensitivity of EUS in diagnosing nodal involvement by rectal cancers was 73.2% (95% confidence interval [95% CI] 70.6-75.6). EUS had a pooled specificity of 75.8% (95% CI 73.5-78.0). The positive likelihood ratio of EUS was 2.84 (95% CI 2.16-3.72), and negative likelihood ratio was 0.42 (95% CI 0.33-0.52). All the pooled estimates, calculated by fixed- and random-effect models, were similar. SROC curves showed an area under the curve of 0.79. The P for chi-squared heterogeneity for all the pooled accuracy estimates was >.10.

CONCLUSIONS

EUS is an important and accurate diagnostic tool for evaluating nodal metastasis of rectal cancers. This meta-analysis shows that the sensitivity and specificity of EUS is moderate. Further refinement in EUS technologies and diagnostic criteria are needed to improve the diagnostic accuracy.

How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Accuracy of endorectal ultrasonography in staging locally advanced rectal cancer after preoperative chemoradiation

AIM

The aim of our study was to determine the accuracy of endorectal ultrasonography (ERUS) in staging locally advanced rectal cancer after preoperative neoadjuvant chemoradiation and to point out the most common reasons for false interpretation.

METHODS

Forty-four patients with locally advanced rectal cancer received neoadjuvant chemoradiation followed by radical surgery. Restaging was done 1-2 weeks before surgery and the results of ERUS staging were compared with histopathology findings of the resected specimen.

RESULTS

The accuracy of ERUS for T stage after chemoradiation was 75% (33/44). Overstaging occurred in 18% (8/44) of patients, and 7% (3/44) were understaged. The majority of overstaging occurred in patients with ERUS T3 tumors, eventually found to have pathological pT0-pT2 staging. Five patients (11.4%) had complete histology regression and only one of these patients was staged correctly while others were overstaged. In the detection of perirectal lymph node metastases, ERUS was accurate in 68% of patients (30/44). Twenty percent (9/44) of patients were overstaged and 11% were (5/44) understaged.

CONCLUSIONS

ERUS provides a good accuracy rate for staging rectal cancer after neoadjuvant chemoradiation. However, it is insufficient in detection of complete pathological response.

Accuracy of endorectal ultrasonography and computed tomography for restaging rectal cancer after preoperative chemoradiation

BACKGROUND

Preoperative restaging of irradiated rectal cancer is essential for the planning of optimal therapy. The aim of this study was to compare the accuracy of endorectal ultrasonography (ERUS) and CT in restaging rectal cancer after preoperative chemoradiation and to evaluate the factors affecting the accuracy of ERUS.

STUDY DESIGN

Eighty-three patients with initial, locally advanced rectal cancer were prospectively evaluated by ERUS (n=60) and CT (n=80) after preoperative chemoradiation and just before surgery. All patients then underwent subsequent surgical resection and complete pathologic staging.

RESULTS

In restaging the depth of invasion, the overall accuracy was 38.3% (23 of 60) by ERUS and 46.3% (37 of 80) by CT. Overstaging was more common than understaging with both imaging modalities. Accuracy for restaging lymph node metastasis was 72.6% (37 of 51) by ERUS and 70.4% (50 of 71) by CT. The predictive value of node-negative cases by ERUS was somewhat lower than that of CT (81.1% versus 85.4%, respectively). Complete pathology-proved remission was not correctly predicted in any of the 11 patients by any imaging modalities. Pathologic T and N staging correlated with the staging accuracy of ERUS (p=0.028 and p=0.001, respectively).

CONCLUSIONS

ERUS and CT may allow good prediction of node-negative rectal cancers, although they are inaccurate modalities for predicting treatment response on the rectal wall. New methods of interpretation and diagnostic criteria for ERUS and CT are essential for increasing the accuracy of cancer prediction in at-risk patients.

Imaging and management of rectal cancer

Local staging and management of rectal cancer has evolved during the past decade. Imaging modalities used for staging rectal cancer include CT, endoscopic ultrasound, pelvic phased-array coil MRI, endorectal MRI, and PET. Each modality has its strengths and limitations. Evidence supports the use of both endoscopic ultrasound and CT in staging rectal cancer. MRI is the only reliable tool for determining the status of the circumferential resection margin, which is important for the assessment of the risk of local recurrence.

Optimal methods for staging rectal cancer

At present, several modalities exist for the preoperative staging of rectal lesions, including computed tomography (CT), body coil or endorectal coil magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) done by rigid or flexible probes, and positron emission tomography (PET). Staging accuracy for CT ranges from 53% to 94% for T-stage accuracy and from 54% to 70% for N-stage accuracy. Improved CT accuracy is observed at higher disease stages. Body coil MRI has shown T- and N-stage accuracy ranging from 59% to 95% and 39% to 95%, respectively. Endorectal coil MRI has shown improved T- and N-stage accuracy, with rates of 66% to 91% and 72% to 79%, respectively. The development of phased-array MRI, combining high spatial resolution with a larger field of view, offers promise to improve on these rates. EUS, considered the current gold standard, has shown T-stage accuracy ranging from 75% to 95%, with N-stage accuracy ranging from 65% to 80%. Flexible EUS probes have the advantage of being able to access and sample iliac nodes. Recent studies also suggest that three-dimensional EUS may provide greater accuracy than conventional two-dimensional EUS. Limited studies exist on the use of PET in primary tumor staging. PET may upstage disease in 8% to 24% of patients and has also been used in posttreatment restaging and surveillance. Postradiation edema, necrosis, and fibrosis seem to decrease restaging accuracy in all modalities. This article reviews the current literature about the staging accuracy of the various modalities and suggests a staging algorithm for rectal cancer.

Is there a limit to dose escalation for rectal cancer?

The radiation tolerance of the rectum is not fully understood. Published studies on the radiation treatment of cancers of the prostate, cervix and rectum have been reviewed to determine currently recommended dose-volume guidelines. The need for further studies directed specifically at the treatment of primary rectal cancer and perirectal node metastases is discussed. There seems to be room for escalation of the external beam doses currently given.

Organ preservation for rectal cancer

Organ preservation with maintenance of function in the treatment of rectal cancer is highly valued by patients. Although most patients with resectable rectal cancer can undergo a sphincter-sparing radical procedure, there are patient, tumor, surgeon, and treatment factors that influence the ability to restore intestinal continuity after radical resection. Although population-based data suggest that the rate of sphincter preservation is lower than could be obtained at expert centers, there are patients in whom low anterior resection with colo-anal anastomosis is not technically feasible and/or oncologically sound. Additionally, resection with ultralow anastomosis results in functional compromise in many patients. Local treatment of rectal cancer aims to decrease the morbidity and the functional sequelae associated with radical resection; however, local excision is associated with a higher rate of local recurrence than is radical resection. Strict selection criteria are essential when considering local excision, and patients should be informed of the risk of local recurrence. The use of adjuvant therapy with local excision, particularly in patients with T2 lesions, has promise but should be considered only as part of a clinical trial.