Survey of rectal cancer MRI technique and reporting tumour descriptors in the UK: a multi-centre British Society of Gastrointestinal and Abdominal Radiology (BSGAR) audit

AIM

To evaluate variation in magnetic resonance imaging (MRI) technique and reporting of rectal cancer staging examinations across the UK.

MATERIALS AND METHODS

A retrospective, multi-centre audit was undertaken of imaging protocols and information documented within consecutive MRI rectal cancer reports between March 2020 and August 2021, which were compared against American and European guidelines. Inclusion criteria included histologically proven rectal adenocarcinoma and baseline staging MRI rectum only.

RESULTS

Fully anonymised data from 924 MRI reports by 78 radiologists at 24 centres were evaluated. Thirty-two per cent of radiologists used template reporting, but these reports offered superior documentation of 13 out of 18 key tumour features compared to free-text reports including T-stage, relation to peritoneal reflection and mesorectal fascia (MRF), nodal status, and presence of extramural venous invasion (EMVI; p<0.027 in each). There was no significant differences in the remaining five features. Across all tumour locations, the tumour relationship to the MRF, the presence of EMVI, and the presence of tumour deposits were reported in 79.5%, 85.6%, and 44% of cases, respectively, and tumour, nodal, and distant metastatic stage documented in 94.4%, 97.7%, and 78.3%. In low rectal tumours, the relationship to the anal sphincter complex was reported in only 54.6%.

CONCLUSION

Considerable variation exists in rectal cancer MRI acquisition and reporting in this sample of UK centres. Inclusion of key radiological features in reports must be improved for risk stratification and treatment decisions. Template reporting is superior to free-text reporting. Routine adoption of standardised radiology practices should now be considered to improve standards to facilitate personalised precision treatment for patients to improve outcomes.

O65: C-MET PROTEIN AS A COLORECTAL CANCER BIOMARKER FOR FLUORESCENCE IMAGE-GUIDED SURGERY

Introduction

The c-Met transmembrane protein is vital for cell differentiation and migration and is overexpressed in many gastrointestinal cancers. This study aimed to investigate a novel c-Met targeted peptide coupled to a fluorophore (EMI-137, Edinburgh Molecular Imaging Ltd.) for use in fluorescence image-guided colorectal cancer (CRC) surgery.

Method

A high c-Met expressing cell-line, HT29, was identified with temporary RNA suppression and used to develop a mouse xenograph CRC model. Tumours were allowed to grow to 10mm. EMI-137 was injected into the tail vein and biodistribution analysed using the IVIS system.

Nine patients undergoing elective surgery for colon cancer received a single IV dose EMI-137 1-3 hours before surgery. Tumour and LN fluorescence was assessed with a prototype Karl Storz laparoscope. Intraoperative fluorescence was correlated with radiological and pathological TNM stage and tissue c-Met expression using immunohistochemistry.

Result

The HT29 xenograph CRC model demonstrated selective EMI-137 uptake and fluorescence 1- 6 hours post administration. Nine participants aged 67-77 years received EMI-137 106 minutes (S.D±17) before surgery. Marked background fluorescence was observed in all patients. 4/9 (44%) patients showed mild increase in tumour fluorescence over background. 5/9 patients had histological LN disease, but no fluorescent nodes were detected intraoperatively. There was no correlation with T-stage. At histopathological assessment 8/9 participants showed moderate or high tumour c-Met expression. 8/8 malignant LNs demonstrated high c-Met expression.

Conclusion

EMI-137 is specific for human c-Met in 2D and xenograph CRC models. EMI-137 is safe for human use but its utility is limited by insufficient tumour-to-background ratios.

Take-home message

This first-in-man study of a novel fluorescent peptide targeted to the c-Met receptor, found EMI-137 lacked the sensitivity and specificity to accurately map the tumour margins and lymph node burden in laparoscopic colonic cancer resection surgery.

Improving practice in radiology: a quality-improvement project examining CT colonography patient dose and scanning technique

AIM

To audit scanning technique and patient doses for computed tomography (CT) colonography (CTC) examinations in a large UK region and to identify opportunities for quality improvement.

MATERIALS AND METHODS

Scanning technique and patient dose data were gathered for both contrast-enhanced and unenhanced CTC examinations from 33 imaging protocols across 27 scanners. Measurements of patient weight and effective diameter were also obtained. Imaging protocols were compared to identify technique differences between similar scanners. Scanner average doses were calculated and combined to generate regional diagnostic reference limits (DRLs) for both examinations.

RESULTS

The regional DRLs for contrast-enhanced examinations were volume CT dose index (CTDIvol) of 11 and 5 mGy for the two scan phases (contrast-enhanced and either delayed phase or non-contrast enhanced respectively), and dose-length product (DLP) of 740 mGy·cm. For unenhanced examinations, these were 5 mGy and 450 mGy·cm. These are notably lower than the national DRLs of 11 mGy and 950 mGy·cm. Substantial differences in scan technique and doses on similar scanners were identified as areas for quality-improvement action.

CONCLUSION

A regional CTC dose audit has demonstrated compliance with national DRLs but marked variation in practice between sites for the dose delivered to patients, notably when scanners of the same type were compared for the same indication. This study demonstrates that the national DRL is too high for current scanner technology and should be revised.

Tumour growth rate of carcinoma of the colon and rectum: retrospective cohort study

BACKGROUND

The growth pattern of colorectal cancer is seldom investigated. This cohort study aimed to explore tumour growth rate in colorectal cancers managed non-surgically or deemed not resectable, and to determine its implication for prognosis.

METHODS

Consecutive patients with colonic or rectal adenocarcinoma were identified through the colorectal multidisciplinary team database at Leeds Teaching Hospitals NHS Trust over a 2-year interval. Patients who received no treatment (surgery, stenting, colonic defunctioning procedures, chemotherapy, radiotherapy) and who underwent CT twice more than 5 weeks apart were included. Multidetector CT/three-dimensional image analysis was performed independently by three experienced radiologists.

RESULTS

Of 804 patients reviewed, 43 colorectal cancers were included in the final analysis. Median age at first CT was 80 (73-85) years and the median interval between scans was 150 (i.q.r. 72-471) days. An increase in T category was demonstrated in 31 of 43 tumours, with a median doubling time of 211 (112-404) days. The median percentage increase in tumour volume was 34·1 (13·3-53·9) per cent per 62 days. The all-cause 3-year mortality rate was 81 per cent (35 of 43) with a median survival time of 1·1 (0·4-2·2) years after the initial diagnostic scan. In those obstructed, the relative risk of death from subsequent perforation was 1·26 (95 per cent c.i. 1·07 to 1·49; P = 0·005).

CONCLUSION

This study documented a median doubling time of 211 days, with a concerning suggestion of tumour progression, which has implications for the current management standard.

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

Objectives

To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis.

Methods

An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed.

Results

In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented.

Conclusion

These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis.

Key Points

• Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis.

• While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation.

• In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06826-5) contains supplementary material, which is available to authorized users.

Radiologist and multidisciplinary team clinician opinions on the quality of MRI rectal cancer staging reports: how are we doing?

AIM

To evaluate the current opinion of magnetic resonance imaging (MRI) reports amongst specialist clinicians involved in colorectal cancer multidisciplinary teams (CRC MDTs).

MATERIALS AND METHODS

Active participants at 16 UK CRC MDTs across a population of 5.7 million were invited to complete a questionnaire, this included 22 closed and three open questions. Closed questions used ordinal (Likert) scales to judge the subjective inclusion of tumour descriptors and impressions on the clarity and consistency of the MRI report. Open (free-text) questions allowed overall feedback and suggestions.

RESULTS

A total of 69 participants completed the survey (21 radiologists and 48 other CRC MDT clinicians). Both groups highlighted that reports commonly omit the status of the circumferential resection margin (CRM; 83% versus 81% inclusion, other clinicians and radiologists, respectively, p>0.05), presence or absence of extra-mural venous invasion (EMVI; 67% versus 57% inclusion, p>0.05), and lymph node status (90% inclusion in both groups). Intra-radiologist agreement across MRI examinations is reported as 75% by other clinicians. Free-text comments included suggestions for template-style reports.

CONCLUSION

Both groups recognise a proportion of MRI reports are suboptimal with key tumour descriptors omitted. There are also concerns around the presentation style of MRI reports and inter- and intra-radiologist report variability. The widespread implementation of standardised report templates may improve completeness and clarity of MRI reports for rectal cancer and thus clinical management and outcomes in rectal cancer.

Acceptability of a new practice development for radiographers focussed on reducing 'never events' related to nasogastric feeding tubes in adult patients

INTRODUCTION

Ascertain if a new practice development designed to reduce 'never events' from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce.

METHODS

Despite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of 'never events' still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system.

RESULTS

There was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession.

CONCLUSION

Evaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous 'never events'. Large scale implementation of this system across the NHS Radiography workforce should be considered.

IntAct: intra-operative fluorescence angiography to prevent anastomotic leak in rectal cancer surgery: a randomized controlled trial

AIM

Anastomotic leak (AL) is a major complication of rectal cancer surgery. Despite advances in surgical practice, the rates of AL have remained static, at around 10-15%. The aetiology of AL is multifactorial, but one of the most crucial risk factors, which is mostly under the control of the surgeon, is blood supply to the anastomosis. The MRC/NIHR IntAct study will determine whether assessment of anastomotic perfusion using a fluorescent dye (indocyanine green) and near-infrared laparoscopy can minimize the rate of AL leak compared with conventional white-light laparoscopy. Two mechanistic sub-studies will explore the role of the rectal microbiome in AL and the predictive value of CT angiography/perfusion studies.

METHOD

IntAct is a prospective, unblinded, parallel-group, multicentre, European, randomized controlled trial comparing surgery with intra-operative fluorescence angiography (IFA) against standard care (surgery with no IFA). The primary end-point is rate of clinical AL at 90 days following surgery. Secondary end-points include all AL (clinical and radiological), change in planned anastomosis, complications and re-interventions, use of stoma, cost-effectiveness of the intervention and quality of life. Patients should have a diagnosis of adenocarcinoma of the rectum suitable for potentially curative surgery by anterior resection. Over 3 years, 880 patients from 25 European centres will be recruited and followed up for 90 days.

DISCUSSION

IntAct will rigorously evaluate the use of IFA in rectal cancer surgery and explore the role of the microbiome in AL and the predictive value of preoperative CT angiography/perfusion scanning.

Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines

The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.

Demonstration of a Na(+)-dicarboxylate cotransporter in bovine adrenocortical cells

Our study found the uptake of [14C]succinate into bovine adrenocortical cells to be sodium-dependent, inhibited by lithium, and to have an apparent K(m) of 146 mumol/l. Succinate uptake was inhibited by glutarate, fumarate, alpha-ketoglutarate, and maleate but not by 2,3-dimethylsuccinate or cis-aconitate, specific inhibitors of the basolateral Na(+)-dicarboxylate transporter of renal proximal tubule cells. Succinate uptake was highest at pH 6.0 and decreased with increasing pH. Transport of succinate was not significantly inhibited by citrate at pH 7.4 whereas at pH 6.0 inhibition of succinate uptake by citrate was small but significant. The affinity of the adrenal dicarboxylate transporter towards succinate ranges in between the low affinity of the renal luminal dicarboxylate transporter and the high affinity of the respective basolateral transporter. The pH dependency of succinate uptake and the missing inhibition by citrate at pH 7.4 differ from both the luminal and from the basolateral dicarboxylate transporters in kidney, liver, intestine, and placenta. These functional characteristics provide evidence for the existence of a Na(+)-dicarboxylate cotransporter in adrenocortical cells which may supply cholesterol metabolism with reducing substrates.

Molecular cloning of magnesium-independent type 2 phosphatidic acid phosphatases from airway smooth muscle

Members of the type 2 phosphatidic acid phosphatase (PAP2) family catalyse the dephosphorylation of phosphatidic acid (PA), lysophosphatidate and sphingosine 1-phosphate. Here, we demonstrate the presence of a Mg(2+)-independent and N-ethymaleimide-insensitive PAP2 activity in cultured guinea-pig airway smooth muscle (ASM) cells. Two PAP2 cDNAs of 923 and 926 base pairs were identified and subsequently cloned from these cells. The ORF of the 923 base pair cDNA encoded a protein of 285 amino acids (Mr = 32.1 kDa), which had 94% homology with human PAP2a (hPAP2a) and which probably represents a guinea-pig specific PAP2a (gpPAP2a1). The ORF of the 926 base pair cDNA encoded a protein of 286 amino acids (Mr = 32.1 kDa) which had 84% and 91% homology with hPAP2a and gpPAP2a1, respectively. This protein, termed gpPAP2a2, has two regions (aa 21-33 and 51-74) of marked divergence and altered hydrophobicity compared with hPAP2a and gpPAP2a1. This occurs in the predicted first and second transmembrane domains and at the extremes of the first outer loop. Other significant differences between gpPAP2a1/2 and hPAP2a, hPAP2b and hPAP2c occur at the cytoplasmic C-terminal. Transient expression of gpPAP2a2 in Cos-7 cells resulted in an approx. 4-fold increase in Mg(2+)-independent PAP activity, thereby confirming that gpPAP2a2 is another catalytically active member of an extended PAP2 family.

Assessment of the extracellular and intracellular actions of sphingosine 1-phosphate by using the p42/p44 mitogen-activated protein kinase cascade as a model

We have investigated the extracellular and intracellular actions of sphingosine 1-phosphate (S1P) by using cultured airway smooth muscle cells. We have demonstrated that exogenous S1P elicited an activation of mitogen-activated protein kinase (p42/p44 MAPK) that was abolished by pertussis toxin (0.1 microg/mL, 24 h), which was used to inactivate Gi. The effect of exogenous S1P might therefore be attributed to an action at a putative Gi-coupled receptor. The regulation of the p42/p44 MAPK cascade by S1P was also shown to include a protein kinase C (PKC)-dependent intermediate step. Platelet-derived growth factor (PDGF) stimulates intracellular S1P formation and was therefore used to evaluate the intracellular action of S1P. This has previously been investigated by others using the sphingosine kinase inhibitors D,L-threo-dihydrosphingosine and N,N-dimethylsphingosine. We have demonstrated here that both inhibitors block the PDGF-dependent activation of p42/p44 MAPK. However, both are also PKC inhibitors, which might account for their effect because PDGF utilises PKC as an intermediate in the regulation of the p42/p44 MAPK cascade. Significantly, sphingosine, which is the substrate of sphingosine kinase and a PKC inhibitor, blocked the activation of p42/p44 MAPK by PDGF with an almost identical concentration dependence compared with D,L-threo-dihydrosphingosine and N,N-dimethylsphingosine. Therefore, the use of so-called sphingosine kinase inhibitors might lead to misleading interpretations because of their additional effect on PKC. Other approaches, such as oligodeoxynucleotide anti-sense against sphingosine kinase, are required to address the intracellular role of S1P.

Bradykinin stimulates cAMP synthesis via mitogen-activated protein kinase-dependent regulation of cytosolic phospholipase A2 and prostaglandin E2 release in airway smooth muscle

Bradykinin stimulates cAMP synthesis in cultured airway smooth muscle (ASM) cells. This occurs via a pathway that involves: (1) the protein kinase C (PKC)-dependent activation of mitogen-activated protein kinase (MAPK); (2) the MAPK-dependent phosphorylation and activation of cytosolic phospholipase A2 (cPLA2) and (3) the utilization of cPLA2-derived arachidonate by the cyclo-oxygenase pathway to produce prostaglandin E2 (PGE2). PGE2 is released and binds to cell surface receptors to stimulate intracellular cAMP synthesis. The signalling pathway was confirmed by the use of PD098059 [the inhibitor of MAPK kinase-1 (MEK-1) activation], AACOCF3 (an inhibitor of cPLA2) and indomethacin (an inhibitor of cyclo-oxygenase), which all reduced bradykinin-stimulated cAMP synthesis. Bradykinin also elicits the inhibition of approx. 60% of the total cAMP phosphodiesterase activity in the cell [Stevens, Pyne, Grady and Pyne (1994) Biochem. J. 297, 233-239]. This is likely to decrease the rate of cAMP degradation markedly and therefore to potentiate PGE2-stimulated cAMP synthesis. Acute treatment of ASM cells with PMA (a direct activator of PKC) also stimulated the MAPK-dependent phosphorylation of cPLA2. However, in contrast with bradykinin, PMA did not stimulate arachidonate release, suggesting that additional signals (e.g. Ca2+ ions) are required for phosphorylation by MAPK to activate cPLA2. PMA was also without effect on PGE2 release and cAMP synthesis. Evidence that PKC can also directly regulate adenylate cyclase was obtained by using cells pretreated with cholera toxin. Under these conditions, PMA stimulated cAMP synthesis independently of arachidonate metabolites. Furthermore the combined treatment of cells with PMA (to activate PKC) and PGE2 (to activate Gs) stimulated synergistic cAMP synthesis. This might be due to the presence of the type 2 adenylate cyclase, which is synergistically activated by Gs and PKC.

Sphingosine prevents diacylglycerol signaling to mitogen-activated protein kinase in airway smooth muscle

Because many agonists utilize diacylglycerol (DAG) to initiate nuclear transcriptional activity via protein kinase C (PKC), we have investigated whether sphingosine might counter DAG. Sphingosine inhibited PKC activity in an isolated airway smooth muscle cell lysate and prevented the activation of mitogen-activated protein kinase (MAPK) by platelet-derived growth factor, bradykinin, and phorbol 12-myristate 13-acetate in intact cells. MAPK activation in response to all the agonists involves PKC. The stimulation of [3H]palmitate-labeled cells with sphingosine, in the presence of butan-1-ol (0.3%, vol/vol), induced an increase in [3H]phosphatidate (PtdOH) but was without effect on [3H]DAG. [3H]PtdOH synthesis was inhibited, whereas [3H]DAG levels were increased in the presence of the DAG kinase inhibitor R-59949, indicating that sphingosine stimulates phospholipase C/DAG kinase. Recycling of DAG from PtdOH was prevented by a sphingosine-dependent inhibition of PtdOH phosphohydrolase-2 activity. In conclusion, the sphingosine-induced conversion of DAG to PtdOH may serve to optimize the effect of sphingosine on MAPK. This may account for the antiproliferative action of sphingosine.

The identification of DL-threo dihydrosphingosine and sphingosine as novel inhibitors of extracellular signal-regulated kinase signalling in airway smooth muscle

We present entirely novel evidence that DL-threo dihydrosphingosine and sphingosine are inhibitors of the extracellular signal-regulated kinase (ERK) signalling cassette in mammalian cells. We show that DL-threo dihydrosphingosine is effective against both growth factor- and G-protein-dependent activation of ERK. We conclude that DL-threo dihydrosphingosine may represent an important pharmacological cell-permeable agent that may be usefully employed to block smooth muscle cell proliferation.

Protein kinase C-dependent cyclic AMP formation in airway smooth muscle: the role of type II adenylate cyclase and the blockade of extracellular-signal-regulated kinase-2 (ERK-2) activation

Bradykinin activates adenylate cyclase via a pathway that involves the 'up-stream' regulation of phospholipase D (PLD)-catalysed hydrolysis of phosphatidylcholine and activation of protein kinase C (PKC) in airway smooth muscle [Stevens, Pyne, Grady and Pyne (1994) Biochem. J. 297, 233-239]. Coincident signal (Gs alpha and PKC) amplification of the cyclic AMP response can be completely attenuated either by diverting PLD-derived phosphatidate or by inhibiting PKC. In this regard, the coincident signal detector type II adenylate cyclase is expressed as a 110/112 kDa polypeptide in these cells. PKC alpha is not involved in the activation of adenylate cyclase, since a B2-receptor antagonist (NPC567, 10 microM) blocked its bradykinin-stimulated translocation to the membrane and was without effect against both bradykinin-stimulated PLD activity and cyclic AMP formation. Cyclic AMP formation can also be activated by platelet-derived growth factor (PDGF), via a PKC-dependent pathway, although the magnitude of the response is less than that elicited by bradykinin. Nevertheless, these results indicate that multiple receptor types employ PKC to initiate cyclic AMP signals. PDGF (10 ng/ml) elicited the marked sustained activation of extracellular-signal-regulated kinase-2 (ERK-2), whereas bradykinin (1 microM) provoked only modest transient activation of ERK-2. Deoxyadenosine (0.1 mM), a P-site inhibitor of adenylate cyclase, blocked bradykinin-stimulated cyclic AMP formation and converted the activation of ERK-2 into a sustained response. Thus the PKC-stimulated cyclic AMP response can limit the activation of ERK-2 in response to bradykinin. These studies indicate that the integration of distinct signal pathways by adenylate cyclase can determine the kinetics of ERK activation, an enzyme that appears to be important for mitogenic progression.

[Improvement of the conditions of rat liver preservation by concomitant perfusion of the liver and kidney]

One of the factors limiting the duration of rat liver storage is the excessive accumulation of catabolites in the perfusion medium. In view of obtaining of an efficient depuration the authors have introduced a new circuit allowing for the concomittant perfusion of the liver and of the kidneys. The excretion effort of the kidneys is assessed by the estimation of urea nitrogen in the perfusion medium and in the urine collected over the entire duration of the experiment. The results have confirmed the good function of the system which provides possibilities for improved storage conditions of rat liver.