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Wang D, Mukhtar A, Humayun M, Wu K, Du Z, Wang S, Zhang Y. A Critical Review on Nanowire-Motors: Design, Mechanism and Applications. CHEM REC 2022; 22:e202200016. [PMID: 35616156 DOI: 10.1002/tcr.202200016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/24/2022] [Indexed: 01/18/2023]
Abstract
Nanowire-motors (NW-Ms) are promoting the rapid development of emerging biomedicine and environmental governance, and are an important branch of micro-nano motors in the development of nanotechnology. In recent years, huge research breakthroughs have been made in these fields in terms of the fascinating microstructure, conversion efficiency and practical applications of NW-Ms. This review article introduces the latest milestones in NW-Ms research, from production methods, driving mechanisms, control methods to targeted drug delivery, sewage detection, sensors and cell capture. The dynamics and physics of micro-nano devices are reviewed, and finally the current challenges and future research directions in this field are discussed. This review further aims to provide certain guidance for the driving of NW-Ms to meet the urgent needs of emerging applications.
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Affiliation(s)
- Dashuang Wang
- College of Materials Science and Engineering, Chongqing University, Chongqing, 400044, China
| | - Aiman Mukhtar
- The State Key Laboratory of Refractories and Metallurgy, International Research Institute for Steel Technology, Collaborative Innovation Center for Advanced Steels, Wuhan University of Science and Technology, Wuhan, 430081, China
| | - Muhammad Humayun
- School of Optical and Electronic Information, Wuhan National Laboratory for Optoelectronics, Engineering Research Center for Functional Ceramics of the Ministry of Education, Huazhong University of Science and Technology, Wuhan, 430074, PR China
| | - Kaiming Wu
- The State Key Laboratory of Refractories and Metallurgy, International Research Institute for Steel Technology, Collaborative Innovation Center for Advanced Steels, Wuhan University of Science and Technology, Wuhan, 430081, China
| | - Zhilan Du
- College of Materials Science and Engineering, Chongqing University, Chongqing, 400044, China
| | - Shushen Wang
- The State Key Laboratory of Refractories and Metallurgy, International Research Institute for Steel Technology, Collaborative Innovation Center for Advanced Steels, Wuhan University of Science and Technology, Wuhan, 430081, China
| | - Yuxin Zhang
- College of Materials Science and Engineering, Chongqing University, Chongqing, 400044, China
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Han C, Tang X, Yang M, Zhang K, Liu J, Lin R, Ding Z. How Useful Is Endoscopic Ultrasound in Differentiating T3/T4a T Stage of Colorectal Cancer: A Prospective Study. Front Oncol 2022; 11:618512. [PMID: 35127462 PMCID: PMC8813747 DOI: 10.3389/fonc.2021.618512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Endoscopic ultrasound (EUS) is an established method for staging of colorectal cancer. Nevertheless, prior assessments of its T stage accuracy have been limited, particularly ambiguity in assessed T3 and T4a stage. This study was to characterize the EUS image features and pay attention to distinguish T3 from T4a T stage. Methods A total of 638 patients who prospectively underwent colorectal EUS were recorded. The final diagnoses were compared with the concurrent or follow-up histopathology. Univariate and multivariate logistic regressions were used to assess variation in diagnostic performance with case attributes. Results The accuracies of EUS in classifying colorectal cancer for overall, T1, T2, T3, and T4a stages are 73.04, 62.32, 67.46, 71.26, and 83.52%, respectively. With attention to EUS image features, the lesion penetrates the entire wall and locates below the seminal vesicles or cervix is T3 stage. If the lesion locates above clearly-defined space between the anterior rectal wall and the posterior surface of the seminal vesicles or cervix, we identify as T4a stage; However, when located above seminal vesicles or cervix but on the posterior wall of the rectum, the lesion still considers as T3 stage. The tumor location and histological type are associated with inaccuracy T stage. Conclusions EUS provides reliable diagnostic accuracy in the colorectal cancer stage. The seminal vesicles and cervix are the important markers to predict infiltration depth for T3/T4a stage. Furthermore, the tumor location, histological type, and EUS image features for each tumor T stage should warrant attention.
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Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuelian Tang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Yang
- Division of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kun Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Rong Lin, ; Zhen Ding,
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Rong Lin, ; Zhen Ding,
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Xian MF, Zheng X, Xu JB, Li X, Chen LD, Wang W. Prediction of lymph node metastasis in rectal cancer: comparison between shear-wave elastography based ultrasomics and MRI. ACTA ACUST UNITED AC 2021; 27:424-431. [PMID: 34003129 DOI: 10.5152/dir.2021.20031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE We aimed to explore the diagnostic efficiency of shear-wave elastography (SWE) ultrasomics in the preoperative prediction of lymph node (LN) metastasis in rectal cancer. METHODS This study included 87 patients with pathologically confirmed rectal cancer, with data gathered from August 2017 to August 2018. A total of 1044 ultrasomics features of rectal tumor were collected with AK software from the SWE examinations. The least absolute shrinkage and selection operator (LASSO) regression model was used for feature selection and building a SWE ultrasomics signature. The diagnostic performance was evaluated with an area under the receiver operating characteristic curve (AUC) analysis. Then, the diagnostic performance of the SWE ultrasomics signature was compared with magnetic resonance imaging (MRI). RESULTS Of the 87 patients, 40 (46.0%) had LN metastasis. Thirteen ultrasomics features of rectal tumor were selected as the most significant features. The SWE ultrasomics signature correlated with LN metastasis (p < 0.001). Patients with LN metastasis had higher signature than patients without LN metastasis. In terms of diagnostic performance, SWE ultrasomics signature was significantly superior to MRI (AUC, 0.883 vs. 0.760, p = 0.034). The diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SWE ultrasomics signature were 82.8%, 87.5%, 78.8%, 77.8%, and 88.1%, respectively, while those of MRI were 75.9%, 77.5%, 74.5%, 72.1%, and 79.6%, respectively. CONCLUSION SWE ultrasomics is a more accurate predictive method for identifying LN metastasis preoperatively than MRI. Thus, SWE ultrasomics might be used to better guide preoperative individual therapies for patients with rectal cancer.
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Affiliation(s)
- Meng-Fei Xian
- Department of Medical Ultrasounics, East division of the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xin Zheng
- Department of Medical Ultrasonics, Ultrasonics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jian-Bo Xu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xin Li
- Research Center of GE Healthcare, Shanghai., China
| | - Li-Da Chen
- Department of Medical Ultrasonics, Ultrasonics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Ultrasonics Artificial Intelligence X-Lab, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Prospective evaluation of the performance and interobserver variation in endoscopic ultrasound staging of rectal cancer. Eur J Gastroenterol Hepatol 2018; 30:1013-1018. [PMID: 29846267 DOI: 10.1097/meg.0000000000001176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment and prognosis of patients with rectal adenocarcinoma (RAC) are dependent on accurate locoregional staging. OBJECTIVES The aim of this study was to measure the performance characteristics of rectal endoscopic ultrasound (EUS) compared with surgical pathology, and to assess the interobserver variation of rectal EUS in the staging of RAC. PATIENTS AND METHODS Patients referred for rectal EUS staging of a recently diagnosed RAC were prospectively enrolled between 2012 and 2016. Tandem EUS exams were performed by two independent endosonographers (ES1 and ES2) blinded to each other's findings. RESULTS Ninety-five patients were enrolled. Seventy-five (79%) underwent curative intent tumor resection, including 30 without neoadjuvant therapy. In this latter group, the sensitivity, specificity, and accuracy of transrectal ultrasonography staging were 75, 83, and 82% for uT1; 50, 65, and 58% for uT2; 56, 81, and 73% for T3; 72, 44, and 63% for N0, and 38, 75, and 63% for N1, respectively. Experienced operators rendered a more accurate N stage and were less likely to overstage compared with less experienced ones (P=0.01 and 0.02, respectively). Overall, T staging agreement between endosonographers was substantial (κ=0.61) and N stage agreement was moderate (κ=0.45). CONCLUSION Rectal EUS is more accurate in staging T1 and T3 tumors compared with T2 tumors. Interobserver agreement of rectal EUS in rectal cancer staging is generally good.
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Civelli EM, Gallino G, Mariani L, Cozzi G, Biganzoli E, Salvetti M, Gallo R, Belli F, Bonfanti G, Bertario L, Andreola S, Leo E. Double-Contrast Barium Enema and Computerised Tomography in the Pre-Operative Evaluation of Rectal Carcinoma: Are they Still Useful Diagnostic Procedures? TUMORI JOURNAL 2018; 86:389-92. [PMID: 11130567 DOI: 10.1177/030089160008600504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose In modern management of rectal carcinoma, the preoperative evaluation of disease parameters is important for selection of therapeutic options. Such parameters are currently defined through endorectal ultrasonography or endoscopic ultrasonography. A retrospective analysis of the parameters obtained with double-contrast barium enema (DCBE) and endorectal balloon computed tomography (CT) was conducted to verify the diagnostic reliability of the radiological techniques and to establish whether there is still an indication for their use. Methods 53 consecutive patients with adenocarcinoma of the distal half of the rectal ampulla underwent double contrast barium enema examination and CT of the pelvis with endorectal balloon. On the basis of the DCBE and CT assessment we evaluated: 1) the distance between the cranial extremity of the anal canal and the distal margin of the neoplasm; 2) the radial diffusion of the tumor; 3) the metastatic involvement of the perirectal and inferior mesenteric lymph nodes. Results 1) CT and DBCE measurements of the distal margin tended to coincide, but both tended to overestimate the measurement when compared to the pathologic examination; 2) in the identification of neoplastic infiltration of perirectal fat (T3) CT had 100% sensitivity, 78.7% specificity and 86.8% accuracy; 3) the CT sensitivity for detecting lymph node metastasis was 52.6%, specificity 85.3% and accuracy 73.6%. Conclusions The diagnostic information provided by the radiological examinations is comparable to that of clinical and instrumental methods currently employed for staging of rectal carcinoma, although the latter are preferred because they are more readily accessible and less costly. DCBE and CT can therefore be usefully employed for staging of cancer of the rectum in those cases in which there are limitations of the current standard methods.
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Affiliation(s)
- E M Civelli
- Department of Radiology, Istituto Nazionale perlo Studio e la Cura dei Tumori, Milan, Italy
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Endorectal ultrasound in the identification of rectal tumors for transanal endoscopic surgery: factors influencing its accuracy. Surg Endosc 2017; 32:2831-2838. [DOI: 10.1007/s00464-017-5988-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 11/19/2017] [Indexed: 02/07/2023]
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Fraum TJ, Owen JW, Fowler KJ. Beyond Histologic Staging: Emerging Imaging Strategies in Colorectal Cancer with Special Focus on Magnetic Resonance Imaging. Clin Colon Rectal Surg 2016; 29:205-15. [PMID: 27582645 DOI: 10.1055/s-0036-1584288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Imaging plays an increasingly important role in the staging and management of colorectal cancer. In recent years, magnetic resonance imaging (MRI) has supplanted transrectal ultrasound as the preferred modality for the locoregional staging of rectal cancer. Furthermore, the advent of both diffusion-weighted imaging and hepatobiliary contrast agents has significantly enhanced the ability of MRI to detect colorectal liver metastases. In clinical practice, MRI routinely provides prognostic information, helps to guide surgical strategy, and determines the need for neoadjuvant therapies related to both the primary tumor and metastatic disease. Expanding on these roles for MRI, positron emission tomography (PET)/MRI is the newest clinical hybrid imaging modality and combines the metabolic information of PET with the high soft tissue contrast of MRI. The addition of PET/MRI to the clinical staging armamentarium has the potential to provide comprehensive state-of-the-art colorectal cancer staging in a single examination.
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Affiliation(s)
- Tyler J Fraum
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
| | - Joseph W Owen
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
| | - Kathryn J Fowler
- Mallinckrodt Institute of Radiology, Washington University, Saint Louis, Missouri
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Bartel MJ, Brahmbhatt BS, Wallace MB. Management of colorectal T1 carcinoma treated by endoscopic resection from the Western perspective. Dig Endosc 2016; 28:330-41. [PMID: 26718885 DOI: 10.1111/den.12598] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/21/2015] [Accepted: 12/25/2015] [Indexed: 12/13/2022]
Abstract
Detection of early colorectal cancer is expected to rise in light of national colorectal cancer screening programs. This The present review article delineates current endoscopic risk assessments, differentiating invasive from non-invasive neoplasia, for high likelihood of lymph node metastasis in early colorectal cancer, also termed high-risk early colorectal cancer, and endoscopic and surgical resection methods from a Western hemisphere perspective.
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Kye BH, Kim HJ, Kim G, Kim JG, Cho HM. Multimodal Assessments Are Needed for Restaging after Neoadjunvant Chemoradiation Therapy in Rectal Cancer Patients. Cancer Res Treat 2015; 48:561-6. [PMID: 26323642 PMCID: PMC4843748 DOI: 10.4143/crt.2015.114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/07/2015] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Restaging after neoadjuvant treatment is done for planning the surgical approach and, increasingly, to determine whether additional therapy or resection can be avoided for selected patients. MATERIALS AND METHODS Local restaging after neoadjuvant chemoradiation therapy (nCRT) was performed in 270 patients with locally advanced (cT3or4 or N+) rectal cancer. Abdomen and pelvic computed tomography (APCT) was used in all 270 patients, transrectal ultrasound (TRUS) in 121 patients, and rectal magnetic resonance imaging (MRI) in 65 patients. Findings according to imaging modalities were correlated with pathologic stage using Cohen's kappa (κ) to test agreement and intra-class correlation coefficient α to test reliability. RESULTS Accuracy for prediction of ypT stage according to three imaging modalities was 45.2% (κ=0.136, α=0.380) in APCT, 49.2% (κ=0.259, α=0.514) in rectal MRI, and 57.9% (κ=0.266, α=0.520) in TRUS. Accuracy for prediction of ypN stage was 66.0% (κ=0.274, α=0.441) in APCT, 71.8% (κ=0.401, α=0.549) in rectal MRI, and 66.1% (κ=0.147, α=0.272) in TRUS. Of 270 patients, 37 (13.7%) were diagnosed as pathologic complete responder after nCRT. Rectal MRI for restaging did not predict complete response. On the other hand, TRUS did predict three complete responders (κ=0.238, α=0.401). CONCLUSION APCT, rectal MRI, and TRUS are unreliable in restaging rectal cancer after nCRT. We think that multimodal assessment with rectal MRI and TRUS may be the best option for local restaging of locally advanced rectal cancer after nCRT.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyung-Jin Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Gun Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jun-Gi Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Marone P, Bellis MD, D’Angelo V, Delrio P, Passananti V, Girolamo ED, Rossi GB, Rega D, Tracey MC, Tempesta AM. Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer. World J Gastrointest Endosc 2015; 7:688-701. [PMID: 26140096 PMCID: PMC4482828 DOI: 10.4253/wjge.v7.i7.688] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/26/2014] [Accepted: 03/20/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Role of Transrectal Ultrasound in Preoperative Local Staging of Carcinoma Rectum and It's Histopathological Correlation. Indian J Surg 2014; 76:21-5. [PMID: 24799779 DOI: 10.1007/s12262-012-0613-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 06/06/2012] [Indexed: 11/26/2022] Open
Abstract
A precise knowledge of depth of invasion of tumor is essential for the planning of treatment of rectal cancer. TRUS is a new diagnostic modality that has become useful in determining depth of invasion preoperatively and the presence or absence of metastatic lymph nodes. Our aim was to determine Role of Transrectal Ultrasound in Preoperative Local Staging of Carcinoma Rectum and it's Histopathological Correlation. TRUS was used in preoperative local staging of 30 patients with carcinoma rectum. 25patients underwent APR (abdomino-perineal resection) & 5 underwent AR. (anterior resection). Preoperative TRUS staging was compared with pathological staging obtained from biopsy of resected specimen. In staging depth of invasion of rectal wall (T stage) overall accuracy was 83.3 %, over staged 10 %, under staged in 6.67 % sensitivity was 92.5 %, and specificity was 62.5 %. In staging lymph nodes (N stage) overall accuracy was 76.67 %, sensitivity was 79.31 %, specificity was 87.5 %. TRUS is a safe and accurate preoperative local staging method for assessment of both depth of invasion of rectal wall and presence or absence of metastatic lymph nodes.
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Abstract
Early rectal cancer (ERC) is defined as invasive adenocarcinoma spreading into, but not beyond, the submucosa or muscularis propria-that is a Dukes'A: T1N0 or T2N0 tumour in the tumour node metastasis (TNM) classification (Taylor et al. 2008). Among these tumours it is suggested that the most superficial T1 tumours least likely to metastasize to local lymph nodes than adenocarcinoma invading deeper where the rich lymphatic and venous plexuses within the submucosa provide a mechanism for tumour spread beyond the rectum. Currently, only about 10 % of patients presenting symptomatically with rectal cancer are diagnosed with early disease; however, up to 30 % of screen detected cancers are being identified as Dukes'A. Thus, the overall detection of early stage tumours is likely to increase following greater implementation in screening programs. The goal of this invited review is to provide recommendations based on the consensus discussion on the information from preoperative imaging that is of relevance for clinical decision-making for patients with early rectal cancer.
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Affiliation(s)
- Jo Waage
- Haukeland University Hospital, Surgical Clinic, Bergen, Norway
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Dewhurst C, Rosen MP, Blake MA, Baker ME, Cash BD, Fidler JL, Greene FL, Hindman NM, Jones B, Katz DS, Lalani T, Miller FH, Small WC, Sudakoff GS, Tulchinsky M, Yaghmai V, Yee J. ACR Appropriateness Criteria pretreatment staging of colorectal cancer. J Am Coll Radiol 2013; 9:775-81. [PMID: 23122343 DOI: 10.1016/j.jacr.2012.07.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 07/31/2012] [Indexed: 02/06/2023]
Abstract
Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Tsung PC, Park JH, Kim YS, Kim SY, Park WW, Kim HT, Kim JN, Kang YK, Moon JS. Miniprobe endoscopic ultrasonography has limitations in determining the T stage in early colorectal cancer. Gut Liver 2013; 7:163-8. [PMID: 23560151 PMCID: PMC3607769 DOI: 10.5009/gnl.2013.7.2.163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 06/06/2012] [Accepted: 06/06/2012] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Mini-probe endoscopic ultrasonography (mEUS) is a useful diagnostic tool for accurate assessment of tumor invasion. The aim of this study was to estimate the accuracy of mEUS in patients with early colorectal cancer (ECC). Methods Ninety lesions of ECC underwent mEUS for pre-treatment staging. We divided the lesions into either the mucosal group or the submucosal group according to the mEUS findings. The histological results of the specimens were compared with the mEUS findings. Results The overall accuracy for assessing the depth of tumor invasion (T stage) was 84.4% (76/90). The accuracy of mEUS was significantly lower for submucosal lesions compared to mucosal lesions (p=0.003) and it was lower for large tumors (≥2 cm) (p=0.034). The odds ratios of large tumors and submucosal tumors affecting the accuracy of T staging were 3.46 (95% confidence interval [CI], 1.05 to 11.39) and 6.25 (95% CI, 1.85 to 25.14), respectively. When submucosal tumors were combined with large size, the odds ratio was 14.67 (95% CI, 1.46 to 146.96). Conclusions The overall accuracy of T stage determination with mEUS was considerably high in patients with ECC; however, the accuracy decreased when tumor size was >2 cm or the tumor had invaded the submucosal layer.
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Affiliation(s)
- Pei Chuan Tsung
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Rectal imaging: part 1, High-resolution MRI of carcinoma of the rectum at 3 T. AJR Am J Roentgenol 2012; 199:W35-42. [PMID: 22733930 DOI: 10.2214/ajr.11.8134] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE MRI is currently the imaging modality of choice for the detection, characterization, and staging of rectal cancer. A variety of examinations have been used for preoperative staging of rectal cancer, including digital rectal examination, endorectal (endoscopic) ultrasound, CT, and MRI. Endoscopic ultrasound is the imaging modality of choice for small and small superficial tumors. MRI is superior to CT for assessing invasion to adjacent organs and structures, especially low tumors that carry a high risk of recurrence. CONCLUSION High-resolution MRI is an accurate and sensitive imaging method delineating tumoral margins, mesorectal involvement, nodes, and distant metastasis. In this article, we will review the utility of rectal MRI in local staging, preoperative evaluation, and surgical planning. MRI at 3 T can accurately delineate the mesorectal fascia involvement, which is one of the main decision points in planning treatment.
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Guckenberger M, Saur G, Wehner D, Sweeney RA, Thalheimer A, Germer CT, Flentje M. Comparison of preoperative short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer. Strahlenther Onkol 2012; 188:551-7. [PMID: 22638934 DOI: 10.1007/s00066-012-0131-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 03/28/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of this work was to perform a single institution comparison between preoperative short-course radiotherapy (SC-RT) and long-course radiochemotherapy (LC-RCHT) for locally advanced rectal cancer. METHODS A total of 225 patients with clinical stage UICC II-III rectal cancer were treated with SC-RT (29 Gy in 10 twice daily fractions followed by immediate surgery; n = 108) or LC-RCHT (54 Gy in 28 fractions with simultaneous 5-fluorouracil (5-FU) ± oxaliplatin chemotherapy followed by delayed surgery; n = 117). All patients in the LC-RCHT cohort and patients in the SC-RT with pathological UICC stage ≥ II received adjuvant chemotherapy. Before 2004, the standard of care was SC-RT with LC-RCHT reserved for patients where downstaging was considered as required for sphincter preservation or curative resection. In the later period, SC-RT was practiced only for patients unfit for radiochemotherapy. RESULTS Patients in the LC-RCHT cohort had a significantly higher proportion of cT4 tumors, clinical node positivity, and lower tumor location. The 5-year local control (LC) and overall survival (OS) were 91% and 66% without differences between the SC-RT and LC-RCHT groups. Acute toxicity was increased during LC-RCHT (grade ≥ II 1% vs. 33%) and there were no differences in postoperative complications. Severe late toxicity grade ≥ III was increased after SC-RT (12% vs. 3%). Of patients aged > 80 years, 7 of 7 patients and 4 of 9 patients received curative surgery after SC-RT and LC-RCHT, respectively. CONCLUSION Despite the fact that patients with worse prognostic factors were treated with LC-RCHT, there were no significant differences in LC and OS between the SC-RT and LC-RCHT group. Age > 80 years was identified as a significant risk factor for LC-RCHT and these patients could be treated preferably with SC-RT.
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Affiliation(s)
- M Guckenberger
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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Kuo LJ, Chiou JF, Tai CJ, Chang CC, Kung CH, Lin SE, Hung CS, Wang W, Tam KW, Lee HC, Liang HH, Chang YJ, Wei PL. Can we predict pathologic complete response before surgery for locally advanced rectal cancer treated with preoperative chemoradiation therapy? Int J Colorectal Dis 2012; 27:613-21. [PMID: 22080392 DOI: 10.1007/s00384-011-1348-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pathologic complete response has been proven to have oncological benefits for locally advanced rectal cancer treated with chemoradiation therapy. The aims of this study are to analyze and determine the factors to predict pathologic complete response for patients treated with preoperative neoadjuvant therapy. METHODS Patients with biopsy-proven, locally advanced rectal cancer were treated neoadjuvantly followed by radical surgical resection. Tumors were re-assessed after completing chemoradiation, including pelvic magnetic resonance images, colonoscopic examination, and re-biopsy. The results of examination were compared with the final pathologic status. RESULTS A retrospective chart review of 166 patients was conducted. Twenty-five patients (15.1%) had pathologic complete response after chemoradiation. The 5-year overall survival rates were better in the complete response group than the residual tumor group (91.1% vs. 70.8%; P = 0.047), and there were also significant differences in the 5-year disease-free survival rates between these two groups (91.1% vs. 70.2%; P = 0.027). The prediction rates for pathologic complete response by re-biopsy, magnetic resonance images, and colonoscopy were 21.4%, 33.3%, and 53.8%, respectively. In addition, when we further combine the results of colonoscopic findings and re-biopsy, the prediction rate for pathologic complete response reached 77.8% (P = 0.009). CONCLUSIONS Combining the results of the re-biopsy and post-treatment colonoscopic findings, we can achieve a good prediction rate for pathologic complete response. Post-treatment magnetic resonance images are not useful tools in predicting tumor clearance following chemoradiation.
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Affiliation(s)
- Li-Jen Kuo
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Evans J, Patel U, Brown G. Rectal cancer: primary staging and assessment after chemoradiotherapy. Semin Radiat Oncol 2011; 21:169-77. [PMID: 21645861 DOI: 10.1016/j.semradonc.2011.02.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Rectal cancer staging is based on 2 principles. The first is an anatomic definition of the tumor allowing for surgical planning. The second is prognostic stage grouping. A given prognostic stage carries different risks of both local and distant recurrence, a selective and tailored approach to preoperative therapy is appropriate. Increasingly, selective approaches enable an overall reduction in morbidity from overtreatment, while allowing aggressive treatment of high-risk patients. Therefore, the aim of preoperative staging is to accurately and reproducibly differentiate between good and poor prognosis tumors. In the preoperative setting, superficial and flat rectal cancers are probably best initially staged using endoscopic ultrasound, and where available magnetic resonance imaging is used for all other rectal cancers because of its proven high sensitivity and specificity in identifying poor-risk patients based on circumferential margin status, the depth of extramural spread, extramural venous invasion, and nodal status. Restaging after neoadjuvant therapy is a challenge to all modalities because of radiation-induced changes, namely fibrosis, edema, inflammation, and necrosis. However, emerging data suggest that reassessment using a combination of high-resolution magnetic resonance imaging, diffusion-weighted imaging, and positron emission tomography/computed tomography scanning may help to provide valuable prognostic information before definitive surgery.
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Lin S, Luo G, Gao X, Shan H, Li Y, Zhang R, Li J, He L, Wang G, Xu G. Application of endoscopic sonography in preoperative staging of rectal cancer: six-year experience. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:1051-1057. [PMID: 21795480 DOI: 10.7863/jum.2011.30.8.1051] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- Shiyong Lin
- Endoscopic and Laser Department, Sun Yat-Sen University Cancer Center, 651 E Dongfeng Rd, 510060 Guangzhou, Guangdong, China
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Ravizza D, Tamayo D, Fiori G, Trovato C, De Roberto G, de Leone A, Crosta C. Linear array ultrasonography to stage rectal neoplasias suitable for local treatment. Dig Liver Dis 2011; 43:636-41. [PMID: 21550864 DOI: 10.1016/j.dld.2011.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/08/2011] [Accepted: 03/27/2011] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Davide Ravizza
- European Institute of Oncology, Division of Endoscopy, Milan, Italy.
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Does a learning curve exist in endorectal two-dimensional ultrasound accuracy? Tech Coloproctol 2011; 15:301-11. [PMID: 21744098 DOI: 10.1007/s10151-011-0711-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Accepted: 06/24/2011] [Indexed: 01/26/2023]
Abstract
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.
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Contrast enhanced MR imaging of female pelvic cancers: Established methods and emerging applications. Eur J Radiol 2011; 78:2-11. [DOI: 10.1016/j.ejrad.2010.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 03/11/2010] [Indexed: 01/30/2023]
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Sani F, Foresti M, Parmiggiani A, D'Andrea V, Manenti A, Amorotti C, Scotti R, Gallo E, Torricelli P. 3-T MRI with phased-array surface coil in the local staging of rectal cancer. Radiol Med 2011; 116:375-88. [PMID: 21225363 DOI: 10.1007/s11547-011-0621-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Accepted: 06/02/2010] [Indexed: 02/07/2023]
Abstract
PURPOSE This study sought to evaluate the diagnostic accuracy of surface-coil 3T magnetic resonance (MR) imaging in the preoperative study of patients with rectal cancer. MATERIALS AND METHODS Thirty patients with histologically proven rectal cancer underwent surface-coil 3T MR imaging with sagittal, paracoronal and para-axial T2-weighted turbo spin echo (TSE) sequences. Slice thickness was 3 mm without gap, field of view 24 cm, matrix 400 × 512. Images were assessed for infiltration of the rectal wall, perirectal fat and pelvic structures. Tumours were staged according to the TNM system, and the MR imaging results were correlated with histopathology. RESULTS In the patients who underwent MR imaging before and after radiotherapy (group 1), the diagnostic accuracy of 3T MR imaging was 88% for T2, 94% for T3 and 88% for T4 cancers. In those who underwent surgical treatment without preoperative radiotherapy (group 2), the diagnostic accuracy was 90% for T2, 87% for T3 and 87% for T4 cancers. CONCLUSIONS The high signal-to-noise ratio coupled with a large field of view enables surface-coil 3T MR imaging to achieve high levels of diagnostic accuracy in the local staging of rectal cancer, and in particular in assessing infiltration of mesorectum and mesorectal fascia.
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Affiliation(s)
- F Sani
- Department of Radiology, Azienda Ospedaliera Universitaria, Policlinico, Modena, Italy.
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Tan KK, Tsang CB. Staging of Rectal Cancer—Technique and Interpretation of Evaluating Rectal Adenocarcinoma, uT1-4, N Disease: 2D and 3D Evaluation. SEMINARS IN COLON AND RECTAL SURGERY 2010; 21:197-204. [DOI: 10.1053/j.scrs.2010.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Punwani S. Diffusion weighted imaging of female pelvic cancers: concepts and clinical applications. Eur J Radiol 2010; 78:21-9. [PMID: 20801592 DOI: 10.1016/j.ejrad.2010.07.028] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 07/30/2010] [Indexed: 12/23/2022]
Abstract
Early applications of diffusion weighted magnetic resonance imaging (DWI) were limited to neuroimaging, concentrating either on stroke or brain tumours. With recent advances in MRI hardware and software DWI is now increasingly being investigated for cancer assessment throughout the body. Clinical applications of DWI relating to female pelvic cancers have largely concentrated on detection, localisation and staging of disease. More recently investigators have started to evaluate the ability of DWI for determining tumour histology and even predicting the outcome of chemoradiation treatment. This article reviews the physical concepts of MR diffusion weighting, illustrates the biophysical basis of diffusion contrast and reports the clinical applications of DWI for cervical, endometrial, ovarian, rectal and bladder tumours.
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Affiliation(s)
- Shonit Punwani
- Department of Academic Radiology, 2nd Floor Podium, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom.
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Arbea L, Díaz-González JA, Subtil JC, Sola J, Hernandez-Lizoain JL, Martínez-Monge R, Moreno M, Aristu J. Patterns of response after preoperative intensity-modulated radiation therapy and capecitabine/oxaliplatin in rectal cancer: is there still a place for ecoendoscopic ultrasound? Int J Radiat Oncol Biol Phys 2010; 81:439-44. [PMID: 20800389 DOI: 10.1016/j.ijrobp.2010.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 05/07/2010] [Accepted: 05/12/2010] [Indexed: 01/13/2023]
Abstract
PURPOSE The main goals of preoperative chemoradiotherapy (CHRT) in rectal cancer are to achieve pathological response and to ensure tumor control with functional surgery when possible. Assessment of the concordance between clinical and pathological responses is necessary to make decisions regarding alternative conservative procedures. The present study evaluates the patterns of response after a preoperative CHRT regimen, and the value of endoscopic ultrasound (EUS) in assessing response. METHODS AND MATERIALS A total of 51 EUS-staged T3 to T4 and/or N0 to N+ rectal cancer patients received preoperative CHRT (intensity-modulated radiation therapy and capecitabine/oxaliplatin (XELOX) followed by radical resection. Clinical response was assesed by EUS. Rates of pathological tumor regression grade (TRG) and lymph node (LN) involvement were determined in the surgical specimen. Clinical and pathological responses were compared, and the accuracy of EUS in assessing response was calculated. RESULTS Twenty-four patients (45%) achieved a major pathological response (complete or >95% pathological response (TRG 3+/4)). Sensitivity, specificity, negative predictive value, and positive predictive value of EUS in predicting pathological T response after preoperative CHRT were 77.8%, 37.5%, 60%, and 58%, respectively. The EUS sensitivity, specificity, negative predictive value, and positive predictive value for nodal staging were 44%, 88%, 88%, and 44%, respectively. Furthermore, EUS after CHRT accurately predicted the absence of LN involvement in 7 of 7 patients (100%) with major pathological response of the primary tumor. CONCLUSION Preoperative IMRT with concomitant XELOX induces favorable rates of major pathological response. EUS has a limited ability to predict primary tumor response after preoperative CHRT, but it is useful for accurately determining LN status. EUS may have a potential value in identifying patients with a very low risk of LN involvement in association with a good pathological response as potential candidates for conservative local surgical protocols.
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Affiliation(s)
- Leire Arbea
- Department of Oncology, Radiation Oncology Division, Clinica Universidad de Navarra, Pamplona, Spain.
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Bipat S, Zwinderman AH. Multivariate fixed- and random-effects models for summarizing ordinal data in meta-analysis of diagnostic staging studies. Res Synth Methods 2010; 1:136-48. [DOI: 10.1002/jrsm.10] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 06/10/2010] [Accepted: 06/29/2010] [Indexed: 01/13/2023]
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Guckenberger M, Wulf J, Thalheimer A, Wehner D, Thiede A, Müller G, Sailer M, Flentje M. Prospective phase II study of preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy--long-term results. Radiat Oncol 2009; 4:67. [PMID: 20025752 PMCID: PMC2806295 DOI: 10.1186/1748-717x-4-67] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/21/2009] [Indexed: 12/20/2022] Open
Abstract
Background To evaluate clinical outcome after preoperative short-course radiotherapy for rectal cancer with twice daily fractions of 2.9 Gy to a total dose of 29 Gy and adjuvant chemotherapy for pathological stage UICC ≥ II. Methods 118 patients (median age 64 years; male : female ratio 2.5 : 1) with pathological proven rectal cancer (clinical stage II 50%, III 41.5%, IV 8.5%) were treated preoperatively with twice daily radiotherapy of 2.9 Gy single fraction dose to a total dose of 29 Gy; surgery was performed immediately in the following week with total mesorectal excision (TME). Adjuvant 5-FU based chemotherapy was planned for pathological stage UICC ≥ II. Results After low anterior resection (70%) and abdominoperineal resection (30%), pathology showed stage UICC I (27.1%), II (25.4%), III (37.3%) and IV (9.3%). Perioperative mortality was 3.4% and perioperative complications were observed in 22.8% of the patients. Adjuvant chemotherapy was given in 75.3% of patients with pathological stage UICC ≥ II. After median follow-up of 46 months, five-year overall survival was 67%, cancer-specific survival 76%, local control 92% and freedom from systemic progression 75%. Late toxicity > grade II was observed in 11% of the patients. Conclusions Preoperative short-course radiotherapy, total mesorectal excision and adjuvant chemotherapy for pathological stage UICC ≥ II achieved excellent local control and favorable survival.
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Berardi R, Mantello G, Scartozzi M, Del Prete S, Luppi G, Martinelli R, Fumagalli M, Grillo-Ruggieri F, Bearzi I, Mandolesi A, Marmorale C, Cascinu S. Locally advanced rectal cancer patients receiving radio-chemotherapy: a novel clinical-pathologic score correlates with global outcome. Int J Radiat Oncol Biol Phys 2009; 75:1437-1443. [PMID: 19386440 DOI: 10.1016/j.ijrobp.2009.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/04/2009] [Accepted: 01/06/2009] [Indexed: 01/08/2023]
Abstract
PURPOSE To determine the importance of downstaging of locally advanced rectal cancer after neoadjuvant treatment. METHODS AND MATERIALS The study included all consecutive patients with locally advanced rectal cancer who underwent neoadjuvant treatment (chemotherapy and/or radiotherapy) in different Italian centers from June 1996 to December 2003. A novel score was used, calculated as the sum of numbers obtained by giving a negative or positive point, respectively, to each degree of increase or decrease in clinical to pathologic T and N status. RESULTS A total of 317 patients were eligible for analysis. Neoadjuvant treatments performed were as follows: radiotherapy alone in 75 of 317 patients (23.7%), radiotherapy plus chemotherapy in 242 of 317 patients (76.3%). Worse disease-free survival was observed in patients with a lower score (Score 1 = -3 to +3 vs. Score 2 = +4 to +7; p = 0.04). CONCLUSIONS Our results suggest that a novel score, calculated from preoperative and pathologic tumor and lymph node status, could represent an important parameter to predict outcome in patients receiving neoadjuvant treatment for rectal cancer. The score could be useful to select patients for adjuvant chemotherapy after neoadjuvant treatment and surgery.
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Affiliation(s)
- Rossana Berardi
- Medical Oncology Unit, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I - GM Lancisi - G Salesi di Ancona, Ancona, Italy.
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Abstract
Squamous cell carcinoma of the rectum is a rare malignancy. It appears to be associated with chronic inflammatory conditions and infections. The clear association seen between Human Papilloma Virus and various squamous cancers has not been firmly established for the squamous cell cancer of the rectum. The presentation is nonspecific and patients tend to present with advanced stage disease. Diagnosis relies on endoscopic examination with biopsy of the lesion. Distinction from squamous cell cancer of the anus can be difficult, but can be facilitated by immunohistochemical staining for cytokeratins. Staging of the cancer with endoscopic ultrasound and computed tomography provides essential information on prognosis and can guide therapy. At present, surgery remains the main therapeutic option; however recent advances have made chemoradiation a valuable therapeutic addition. Squamous cell carcinoma of the rectum is a distinct entity and it is of crucial importance for the practicing Gastroenterologist to be thoroughly familiar with this disease. Compared to adenocarcinoma of the rectum and squamous cell cancer of the anal canal, squamous cell carcinoma of the rectum has different epidemiology, etiology, pathogenesis, and prognosis but, most importantly, requires a different therapeutic approach. This review will examine and summarize the available information regarding this disease from the perspective of the practicing gastroenterologist.
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Abstract
INTRODUCTION Preoperative staging of rectal cancer is considered essential to select patients adequately for different therapeutic regimes. The aim of the present study was to evaluate the accuracy of endorectal ultrasonography in preoperative staging of rectal cancer. MATERIALS AND METHODS Fifty rectal cancer patients (31 men, 19 women) underwent endorectal ultrasonography with a 7.5-MHz probe. Thirty-eight of these patients had preoperative chemoradiation and in these patients examination was done before and after the radiotherapy treatment. The results of examinations were compared with the histological findings of the resected specimens. RESULTS Histopathology showed 4 stage TO, 3 stage T1, 12 stage T2, 30 stage T3, and one stage T4 tumor. Nodal metastases were seen in 17 patients. The overall accuracy of endorectal ultrasonography for determining the depth of invasion (T stage) was 66% (33/50). The accuracy rate of T1 was 100% (1/1), T2 was 45% (9/20), T3 was 79% (22/28), and T4 was 100% (1/1). Overstaging was 18% (9/50) and understaging 16% (8/50). In staging lymph node metastasis, the overall accuracy rate was 70% (18/25) with 18% (9/50) overstaged and 12% (6/50) understaged With regard to nodal involvement, sensitivity was 65% and specificity 73%. Regarding penetration of the rectal wall (stages T1 and T2 vs stages T3 and T4/Dukes' classification A versus B), endorectal sonography showed sensitivity, specificity, and accuracy of 74%, 68%, and 72%, respectively. CONCLUSION Endorectal ultrasonography is a valuable diagnostic modality for rectal cancer staging. It is fast, safe, accurate, well tolerated by the patient and cheap procedure and therefore should be used as a diagnostic modality of the first choice in rectal cancer staging although one must take into consideration possible limitations in cases of preoperative chemoradiation.
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Abstract
Among imaging techniques, magnetic resonance imaging (MRI) has evolved as the most robust technique for the detection, characterization, and staging of anorectal cancers. With its superior contrast resolution, multiplanar imaging capability, and nil radiation risk, it has become the standard preoperative imaging tool in rectal tumors. In this article we aim to outline the various types of anorectal cancers, highlight the complex anatomy of this region, and discuss the immensely useful role of MRI in the management of anorectal cancers. Existing limitations and future applications in this area will also be discussed. Because rectal adenocarcinomas constitute the majority of tumors in this region, we will be discussing the input of MRI in the management of this condition in greater detail. This will be followed by an overview of MRI in anal carcinoma and other less common anorectal neoplasms.
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Affiliation(s)
- Girish Raghunathan
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Esclapez P, Garcia-Granero E, Flor B, García-Botello S, Cervantes A, Navarro S, Lledó S. Prognostic heterogeneity of endosonographic T3 rectal cancer. Dis Colon Rectum 2009; 52:685-91. [PMID: 19404075 DOI: 10.1007/dcr.0b013e31819ed03d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE This study aimed to assess the prognostic implications of uT3 rectal carcinomas according to the tumor thickness and to analyze the correlation between this ultrasound-based parameter and other prognostic factors. METHODS Seventy-four patients with uT3(pM0) rectal tumors underwent primary surgery from 1996 to 2003. Preoperative endorectal ultrasound was used to assess uN stage, maximum tumor perimeter, and maximum tumor thickness. An ultrasound maximum tumor thickness cutoff point for local recurrence subdividing T3 tumors into uT3a and uT3b was established. RESULTS Median follow-up was 41 months (range, 24-59). The 5-year actuarial local and overall recurrence rates were 9.82 percent (n = 7) and 42.46 percent (n = 23), respectively. uN stage(P = 0.05), circumferential resection margin involvement (P = 0.002), an ultrasound maximum tumor thickness (P = 0.01), and locally advanced tumors (P = 0.001) were related to a significantly increased risk of local recurrence. An ultrasound maximum tumor thickness (hazard ratio, 1.15; 95 percent confidence interval, 1.0-1.2) and locally advanced tumor (hazard ratio, 17.21; 95 percent confidence interval, 2.99-98.84) were preoperative independent variables for predicting local recurrence. Locally advanced tumor was the only preoperative independent prognostic factor for overall recurrence (P = 0.004; hazard ratio, 1.09; 95 percent confidence interval, 1.0-1.1). An ultrasound maximum tumor thickness with a 19-mm cutoff point, subdividing the T3 tumors into uT3a and uT3b, can be used to predict local recurrence. Locally advanced tumors (P = 0.02) and circumferential resection margin involvement (P = 0.005) showed a significant association with an ultrasound maximum tumor thickness >19 mm. CONCLUSIONS A maximum tumor thickness measured by endorectal ultrasound in pT3 rectal cancer is an independent prognostic factor for local and overall recurrence. An ultrasound maximum tumor thickness cutoff point of 19 mm may be useful to classify patients preoperatively and to select them for primary surgery or neoadjuvant therapy.
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Affiliation(s)
- Pedro Esclapez
- Coloproctology Unit, Multidisciplinary Rectal Cancer Team, Hospital Clinico, University of Valencia, Valencia, Spain
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35
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Zorcolo L, Fantola G, Cabras F, Marongiu L, D’Alia G, Casula G. Preoperative staging of patients with rectal tumors suitable for transanal endoscopic microsurgery (TEM): comparison of endorectal ultrasound and histopathologic findings. Surg Endosc 2009; 23:1384-9. [DOI: 10.1007/s00464-009-0349-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 12/14/2008] [Accepted: 01/08/2009] [Indexed: 12/16/2022]
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Abstract
Endorectal ultrasound (ERUS) is a primary imaging technique in the preoperative evaluation of patients with rectal adenocarcinoma. The purpose of this report is to review ultrasound staging with emphasis on technique and potential pitfalls. The role of ultrasound in multimodality staging and surveillance is also explored. An awareness of inherent imaging challenges and implications may optimize staging accuracy and resultant management of rectal cancer patients.
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Affiliation(s)
- Katherine M Krajewski
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Puli SR, Reddy JBK, Bechtold ML, Choudhary A, Antillon MR, Brugge WR. Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review. Ann Surg Oncol 2009; 16:1255-65. [PMID: 19219506 DOI: 10.1245/s10434-009-0337-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Revised: 12/23/2008] [Accepted: 12/23/2008] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Srinivas R Puli
- Division of Gastroenterology and Hepatology, University of Missouri-Columbia, Columbia, MO, USA.
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38
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Chun HK, Cho YB, Lee YJ. Rectal Cancer: Preoperative Staging Using Endorectal Ultrasonography (Methodology). COLORECTAL CANCER 2009. [DOI: 10.1007/978-1-4020-9545-0_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Puli SR, Bechtold ML, Reddy JBK, Choudhary A, Antillon MR, Brugge WR. How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review. Ann Surg Oncol 2008; 16:254-65. [PMID: 19018597 DOI: 10.1245/s10434-008-0231-5] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 10/01/2008] [Accepted: 10/02/2008] [Indexed: 12/15/2022]
Abstract
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.
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40
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Abstract
The treatment of rectal neoplasia, whether benign or malignant, challenges the surgeon. The challenge in treating rectal cancer is selecting the proper approach for the appropriate patient. In a small number of rectal cancer patients local excision may be the best approach. In an attempt to achieve two goals-cure of disease with a low rate of local failure and maintenance of function and quality of life-multiple approaches can be utilized. The key to obtaining a good outcome for any one patient is balancing the competing factors that impact on these goals. Any effective treatment aimed at controlling rectal cancer in the pelvis must take into account the disease in the bowel wall itself and the disease, or potential disease, in the mesorectum. The major downside of local excision techniques is the potential of leaving untreated disease in the mesorectum. Local management techniques avoid the potential morbidity, mortality, and functional consequences of a major abdominal radical resection and are thus quite effective in achieving the maintenance of function and quality of life goal. The issue for the transanal techniques is how they fare in achieving the first goal-cure of the cancer while keeping local recurrence rates to an absolute minimum. Without removing both the rectum and the mesorectum there is no completely accurate way to determine whether a rectal cancer has moved outside the bowel wall, so any decision on local management of a rectal neoplasm is a calculated risk. For benign neoplasia, the challenge is removing the lesion without having to resort to a major abdominal procedure.
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Affiliation(s)
- John Touzios
- Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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41
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Bachet JB, Benoist S. [Management of superficial rectal cancers]. ACTA ACUST UNITED AC 2008; 145:312-22. [PMID: 18955920 DOI: 10.1016/s0021-7697(08)74309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Superficial rectal cancers consist of Tis and T1 tumors as defined by the TNM classification system. Earlier detection of colorectal cancers through endoscopic screening should lead to an increase in the percentage of superficial cancers detected while still superficial; they may eventually represent more than a third of diagnosed rectal cancers. Endorectal ultrasound, ideally performed with a mini-probe, is the best pre-operative study to define the level of penetration into the rectal wall; depth of penetration and grade of differentiation are the major factors to be considered when contemplating local excision as an alternative to radical resection. Local excision can be performed endoscopically or by the classic transanal surgical approach. Each technique has pros and cons and the two are often complementary. Compared to the alternative of radical proctectomy, they have the decided advantages of zero mortality, minimal morbidity, and decreased expense. Pathologic examination of the resected specimen is the final determinant as to whether local resection is adequate therapy. When histologic prognostic factors are favorable (well-differentiated, absence of lymphatic or vascular invasion, superficial invasion of the submucosa (sm1), and clear resection margins), the risk of lymph node spread is negligible. When histologic prognostic factors are not favorable, a completion radical proctectomy should be performed.
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Affiliation(s)
- J-B Bachet
- Fédération des spécialités digestives, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré - Boulogne
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42
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Goertz RS, Fein M, Sailer M. Impact of biopsy on the accuracy of endorectal ultrasound staging of rectal tumors. Dis Colon Rectum 2008; 51:1125-9. [PMID: 18478299 DOI: 10.1007/s10350-008-9222-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 08/25/2007] [Accepted: 10/14/2007] [Indexed: 01/05/2023]
Abstract
PURPOSE Endorectal ultrasound is a well-established method for the preoperative staging of rectal tumors. This prospective study was performed to establish whether obtaining a biopsy before endorectal ultrasound has an influence on staging accuracy. METHODS Between 1990 and 2003, a total of 333 rectal tumors were examined preoperatively by using endorectal ultrasound. All patients underwent rectal resection, and the specimens were sent for histologic evaluation. Thirty-three were not biopsied, the remaining at various times before endorectal ultrasound. The chi-squared test or Fisher's exact test were used for statistical analysis to compare the accuracies. RESULTS The overall staging accuracy was 71 percent but differed significantly (P = 0.004) between the groups as a function of time elapsed since biopsy. The best results were seen in tumors that were not biopsied before endorectal ultrasound, which were correctly staged in 85 percent of the cases. The least accurate staging (53 percent) was noted when endorectal ultrasound was performed in the third week after biopsy, mostly as a result of overstaging. Biopsy did not have a significant effect on nodal staging. CONCLUSIONS Biopsy before endorectal ultrasound significantly affects its accuracy. To achieve the most accurate staging, biopsy should be performed after endorectal ultrasound. Endorectal ultrasound staging performed in the first week after biopsy is the second best option but should be interpreted with caution in the second or third week.
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Affiliation(s)
- Ruediger S Goertz
- Department of Medicine I, Friedrich-Alexander-University, Ulmenweg 18, 91054, Erlangen, Germany.
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43
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Penna C. [Rectal adenocarcinoma: appropriate pretherapeutic explorations by tumor type]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:S126-S132. [PMID: 18467051 DOI: 10.1016/j.gcb.2008.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- C Penna
- Fédération des spécialités digestives, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
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44
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LeBlanc JK. Imaging and management of rectal cancer. ACTA ACUST UNITED AC 2008; 4:665-76. [PMID: 18043676 DOI: 10.1038/ncpgasthep0977] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 08/31/2007] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Julia K LeBlanc
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN 46202, USA.
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45
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Landmann RG, Wong WD, Hoepfl J, Shia J, Guillem JG, Temple LK, Paty PB, Weiser MR. Limitations of early rectal cancer nodal staging may explain failure after local excision. Dis Colon Rectum 2007; 50:1520-5. [PMID: 17674104 DOI: 10.1007/s10350-007-9019-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Successful selection of patients with rectal cancer for local excision requires accurate preoperative lymph node staging. Although endorectal ultrasound is capable of detecting locally advanced disease, its ability to correctly identify nodal metastases in early rectal lesions is less well described. This study examines the accuracy of endorectal ultrasound in determining nodal stage based on depth of penetration of the primary lesion (T stage). Between 1998 and 2003, endorectal ultrasound was performed on 938 consecutive patients; 134 had biopsy-proven rectal cancers and were treated with radical resection, without neoadjuvant therapy. Lymph node metastases were measured pathologically and correlated with endorectal ultrasound and clinicopathologic features. Accuracy and specificity of endorectal ultrasound nodal staging was determined. The overall accuracy of endorectal ultrasound nodal staging for the study cohort was 70 percent, with a 16 percent false-positive rate and 14 percent false-negative rate. Endorectal ultrasound was more likely to overlook small metastatic lymph node deposits. The size of lymph node metastasis and accuracy of endorectal ultrasound nodal staging was related to T stage. The specificity of endorectal ultrasound nodal staging, or the ability to identify patients who were node-negative, was dependent on T stage. Early rectal lesions are more likely to have lymph node micrometastases not detected by endorectal ultrasound. The ability of endorectal ultrasound to correctly identify patients without lymph node metastasis is dependent on the T stage of the primary lesion. The limitations of endorectal ultrasound in accurately staging nodal disease in early rectal lesions may, in part, explain the relatively high recurrence rates seen after local excision.
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Affiliation(s)
- Ron G Landmann
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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46
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Badger SA, Devlin PB, Neilly PJD, Gilliland R. Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve? Int J Colorectal Dis 2007; 22:1261-8. [PMID: 17294198 DOI: 10.1007/s00384-007-0273-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Endorectal ultrasound (ERUS) is becoming an essential tool in the management of rectal cancer. However, accuracy in the assessment of disease staging may be dependent on operator experience. The aim of this study was to determine if a learning curve exists. MATERIALS AND METHODS From October 1999 to December 2004, all patients with rectal cancer had a pre-operative ERUS performed by a single radiologist. ERUS staging was compared with post-operative pathology findings using the tumour, node, metastases (TNM) classification. The accuracy of ERUS in tumour (T) and node (N) staging after each additional consecutive ten patients was calculated. RESULTS One hundred and thirty one patients were investigated by ERUS, of which 36 were excluded, leaving 95 patients in the study (60 men). Overall accuracy for T staging was 71.6%. No improvement with experience was noted (p > 0.05). With regard to T staging, ERUS tended to overstage more frequently than understage (24.2 versus 4.2%). The sensitivity, specificity, positive predictive value and negative predictive value of uT3 staging were 96.6, 33.3, 70.4 and 85.7%, respectively. Overall accuracy of uN staging was 68.8%. ERUS tended to overstage nodal disease more frequently than understage (16.1 versus 15.1%). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for ultrasound-detected nodal disease (73.2, 62.2, 74.5 and 60.5%, respectively). Nodal staging accuracy improved from 50% after assessment of 10 cases to 77% after 30 cases were examined. CONCLUSIONS ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.
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Affiliation(s)
- S A Badger
- Department of Surgery, Altnagelvin Area Hospital, Glenshane Road, Northern Ireland, UK.
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47
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Bipat S, Zwinderman AH, Bossuyt PMM, Stoker J. Multivariate random-effects approach: for meta-analysis of cancer staging studies. Acad Radiol 2007; 14:974-84. [PMID: 17659244 DOI: 10.1016/j.acra.2007.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/08/2007] [Accepted: 05/08/2007] [Indexed: 12/12/2022]
Abstract
RATIONALE AND OBJECTIVES Meta-analyses of diagnostic accuracy studies produce summary estimates of sensitivity and specificity. Cancer staging relies on staging systems and meta-analysis is often performed after dichotomization of the staging results. For each dichotomization, summary estimates of sensitivity and specificity can be calculated by repeated bivariate random-effects analyses. In this process, staging information is lost and under- and overstaging can not be adequately expressed. MATERIALS AND METHODS We propose a new multivariate random-effects approach, which is an extension of the bivariate random-effects approach. To illustrate the principles and outcomes of both approaches, we used data from a meta-analysisevaluating endoluminal ultrasonography in staging of rectal cancer. In the multivariate approach, results on correct staging and under- and overstaging were calculated. In addition, the results from this analysis were used to calculate sensitivity and specificity estimates for each dichotomization and these estimates were compared with the results of the repeated bivariate analyses. RESULTS By the multivariate analysis, results on correct staging and under- and overstaging were obtained. The sensitivity and specificity estimates for the dichotomizations, calculated from the results of this multivariate approach, were also comparable with the sensitivity and specificity estimates obtained by the repeated bivariate analyses. CONCLUSIONS The multivariate random-effects approach can be a useful meta-analytic method for summarizing cancer staging data presented in diagnostic accuracy studies.
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Affiliation(s)
- Shandra Bipat
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
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Rovera F, Dionigi G, Iosca S, Carrafiello G, Recaldini C, Boni L, Carcano G, Diurni M, Dionigi R. Preoperative assessment of rectal cancer stage: state of the art. Expert Rev Med Devices 2007; 4:517-22. [PMID: 17605687 DOI: 10.1586/17434440.4.4.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25-30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method's advantages and limits for their routine use in clinical practice.
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Affiliation(s)
- Francesca Rovera
- Clinical Lecturer, Department of Surgical Sciences, University of Insubria, Azienda Ospedaliero-Universitaria, Fondazione Macchi, Viale Borri 57, 21100 Varese, Italy.
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Koch M, Antolovic D, Kienle P, Horstmann J, Herfarth C, von Knebel Doeberitz M, Weitz J. Increased detection rate and potential prognostic impact of disseminated tumor cells in patients undergoing endorectal ultrasound for rectal cancer. Int J Colorectal Dis 2007; 22:359-65. [PMID: 16758164 DOI: 10.1007/s00384-006-0152-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hematogenous tumor-cell dissemination during diagnostic and therapeutic procedures in patients with colorectal cancer has been demonstrated. OBJECTIVE The aim of this study was to investigate the extent of disseminated tumor cells in blood samples of rectal cancer patients after endorectal ultrasound and to determine its prognostic relevance. MATERIALS AND METHODS Peripheral venous blood samples from 45 patients with rectal cancer were taken before and after endorectal ultrasound. Blood samples were examined using a reverse transcriptase-polymerase chain reaction (RT-PCR) assay to amplify cytokeratin 20 transcripts. Overall survival of the patients was calculated by the Kaplan-Meier method. RESULTS Disseminated tumor cells were detected in peripheral blood samples of 17 of 45 (38%) patients before and after endorectal ultrasound. Circulating tumor cells were found in 11 of 45 (24%) patients only after endorectal ultrasound (p=0.006). There was a clear trend toward a worse prognosis in patients with tumor cells in blood samples after endorectal ultrasound, but this difference was not statistically significant. CONCLUSION This study demonstrates significantly increased hematogenous tumor-cell dissemination after endorectal ultrasound in rectal cancer patients. Patients with tumor cells in blood samples after endorectal ultrasound tend to have a worse prognosis. The potential prognostic impact of this finding is presently unclear and has to be further validated in larger clinical trials.
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Affiliation(s)
- Moritz Koch
- Department of Surgery, University of Heidelberg, INF 110, Heidelberg 69120, Germany
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50
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Valenti V, Hernandez-Lizoain JL, Baixauli J, Pastor C, Aristu J, Diaz-Gonzalez J, Beunza JJ, Alvarez-Cienfuegos JA. Analysis of Early Postoperative Morbidity Among Patients with Rectal Cancer Treated with and without Neoadjuvant Chemoradiotherapy. Ann Surg Oncol 2007; 14:1744-51. [PMID: 17334851 DOI: 10.1245/s10434-006-9338-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 12/19/2006] [Indexed: 01/13/2023]
Abstract
BACKGROUND The impact of neoadjuvant treatment and their subsequent early complications in the treatment of rectal cancer has not been adequately assessed. The aim of this prospective study was to evaluate early postoperative morbidity and mortality among patients with rectal cancer treated with adjuvant radiotherapy and chemotherapy followed by surgery, compared with patients treated with surgery alone. We also identified independent risk factors associated with early major complications. METHODS Between 1995 and 2004, 273 consecutive patients underwent treatment for rectal cancer. A total of 170 patients (group A) received preoperative radiotherapy with a total of 45-50.4 Gy (180 cGy per day) and 5-fluorouracil-based chemotherapy, followed by surgery; 103 patients (group B) were treated with surgery alone. Dependent variables related to patients, treatment, radiotherapy, and tumor were analyzed. RESULTS Both groups were similar with regard to age, sex, body mass index, American Society of Anesthesiologists (ASA) score, and tumor location but not for ileostomy (27% in group A vs. 6.8% in group B). The number of complications was similar in both groups (43.1% in group A vs. 44.6% in group B). No differences in wound infection (8.2% vs. 7.8%), intra-abdominal abscess (4.7% vs. 4.9%), anastomotic dehiscence (4.2% vs. 3.8%), postoperative hemorrhage (3.5% vs. 3.9%), urinary complications (6.5% vs. 4.9%), paralytic ileus (8.9% vs. 9.7%), or general complications (7.1% vs. 9.6%) were found. The global mortality in the first 30 days after surgery was .7%. An ASA score of III-IV and surgery duration longer than 3 hours were identified as independent prognostic factors for early complications. CONCLUSIONS Preoperative chemoradiation in patients with rectal cancer treated with surgery is not associated with a higher incidence of early postoperative complications. The patient's preoperative clinical condition and lengthy surgery time are prognostic factors for early complications.
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Affiliation(s)
- Victor Valenti
- Department of Surgery, Clinica Universitaria de Navarra, University of Navarra, Avda. Pio XII, 36, 31080, Pamplona, Spain.
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