Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging

Brown, Gina; Radcliffe, A. G.; Newcombe, Robert G.; Dallimore, N S; Bourne, Michael W.; Williams, Geraint T.

doi:10.1002/bjs.4034

Cited by 650 publications

(473 citation statements)

References 23 publications

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“…This correlation was reported by Brown et al (2003) in a single-centre experience and has been described by other centres (Blomqvist et al, 1999;BeetsTan et al, 2001;Bissett et al, 2001;Botterill et al, 2001). A large international prospective multicentre study (MERCURY trial) has demonstrated that the extent of tumour seen on the preoperative MRI scan is equivalent to that seen in the resected pathological specimen in patients who undergo initial surgery with or without short-course preoperative radiotherapy (MERCURY Study Group, 2006).…”

supporting

confidence: 53%

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

et al. 2007

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There is increasing evidence supporting the use of preoperative chemoradiotherapy in patients with locally advanced rectal cancer in an attempt to facilitate complete surgical resection with clear margins. We describe our experience of using a 5-day per week regime of preoperative capecitabine chemoradiotherapy. Between November 2004 and September 2006, 70 patients with MRI-defined locally advanced rectal cancer were selected for treatment. Capecitabine was given at a dose of 900 mg m À2 for 5 days per week combined with 45 Gy of radiotherapy in 25 doses. This regime was well tolerated with 89% of our patients receiving the full dose of chemotherapy and 96% receiving the full dose of radiotherapy. Ninety-three per cent proceeded to macroscopically complete surgical resection. The pathological complete response rate was 9.2% with a node-negative rate of 66%. A negative circumferential margin was achieved by 79% of the patients who underwent resection. Compared to studies using a 7-day per week capecitabine schedule, our results show increased compliance and less dose reductions with comparable pathological outcome. There is clear evidence from two systematic reviews that adjuvant radiotherapy reduces the risk of local recurrence in patients with resectable rectal cancer (Camma et al, 2000; Colorectal Cancer Collaborative, 2001). The greatest benefit is seen when preoperative radiotherapy is used with a biologically equivalent dose of 430 Gy. Further clinical trials were required to assess the benefit of adding concurrent chemotherapy to preoperative radiotherapy.The recent publication of two phase III trials confirms that preoperative concurrent chemoradiation (CRT) is superior to long-course radiotherapy alone in patients with T3/4 or nodepositive resectable rectal cancer. The EORTC 22921 (Bosset et al, 2005) and FFCD 9203 (Gerard et al, 2006) trials compared intravenous 5-fluorouracil (5FU) and leucovorin (LV) given during the first and fifth weeks of radiotherapy with radiotherapy alone (dose of RT was 45 Gy in 25 fractions in both arms of the studies). Both trials demonstrated a reduction in the rates of local recurrence at 5 years from 17% with radiotherapy alone to 8 -9% with preoperative CRT, but neither trial showed any difference in overall survival. A further recent phase III trial has demonstrated that preoperative 5FU CRT is superior to post-operative CRT with a significant reduction in local recurrence from 12 to 6% as well as a significant reduction in both acute and long-term toxicity (Sauer et al, 2004). This evidence will clearly result in an increasing use of fluoropyrimidine-based CRT.Intravenous 5FU-based chemoradiation presents many logistical challenges. Continuous infusion of 5FU requires the insertion of a central venous line with its attendant risks of thrombosis and infection as well as the inconvenience of a portable infusion pump. The use of the bolus 5FU/LV regimen used in the EORTC and FFCD trials requires 10 daily visits to the chemotherapy day unit, with associated waiting time, t...

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supporting

confidence: 53%

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

et al. 2007

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“…In nonirradiated patients, tumor involvement of the resection margin could be predicted or excluded with a high reliability (PPV 80% and NPV 89%). These results are not in agreement with those reported in a recent review by Dent et al (5), who found a generally low PPV, ranging from 20% to 80%, except for a PPV of 89% reported by Brown et al (9). Because our results showed a significant negative influence of chemoradiation on the reliability of MRI in assessing the mrMF status (PPV reduced to 42 %), caution should be exercised when discussing previous studies that included irradiated patients.…”

Section: Discussioncontrasting

confidence: 99%

“…However, many of the previous investigations included irradiated patients (6)(7)(8)(9)(10)(11)(12) and it is known that the value of MRI restaging after chemoradiation is reduced, because of posttherapeutic inflammation and fibrosis (13)(14)(15)(16). To our knowledge, the impact of chemoradiation on the reliability of MRI in assessing tumor involvement of the mesorectal fascia has not been analyzed previously in a comparative study.…”

mentioning

confidence: 99%

Rectal Cancer: MR imaging of the mesorectal fascia and effect of chemoradiation on assessment of tumor involvement

Oberholzer¹,

Junginger²,

Heintz³

et al. 2012

Magnetic Resonance Imaging

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Purpose: To evaluate the impact of chemoradiation on the reliability of MRI in assessing tumor involvement of the mesorectal fascia in patients with rectal cancer. Materials and Methods:Presurgical MRI was performed in 150 patients; among them 85 had received neoadjuvant long-course chemoradiation. A standardized imaging protocol (1.5 Tesla [T] system, image voxel size 0.6 Â 0.4 Â 3 mm 3 ), standardized surgery, and histopathological examination were applied for the entire patient population. Images were analyzed to identify potential tumor involvement of the mesorectal fascia (minimum tumor distance to fascia 1 mm) and compared with histopathology as the reference standard. Results of nonirradiated and irradiated patients were compared to define the impact of chemoradiation on imaging reliability.Results: In nonirradiated patients, MRI was reliable in predicting or excluding tumor involvement of the mesorectal fascia, positive predictive value 80%, negative predictive value 89%. The frequency of overestimating tumor involvement was significantly higher in irradiated patients (P ¼ 0.005, positive predictive value 42%).Conclusion: Discussions about MRI assessment of tumor involvement of the mesorectal fascia as a basis for recommending neoadjuvant chemoradiation should focus on investigations that excluded irradiated patients, because MRI is less reliable after chemoradiation and tends to overestimate mesorectal tumor involvement. ASSESSING THE LOCAL tumor stage in patients with rectal cancer before initiating treatment forms the basis for therapeutic decision-making. Patients at a high risk for local recurrence should be referred to neoadjuvant chemoradiation. The indication for neoadjuvant therapy is commonly based on the clinical T and N categories. Because the minimum distance between the tumor and the circumferential resection margin (CRM) was identified as an independent prognostic factor for local recurrence after primary total mesorectum excision (1,2), pretherapeutic evaluations have increasingly focused on the CRM status.High resolution MRI can assess both the tumor and the distance to the mesorectal fascia (i.e., surgical plane) and thus enabling predictions of the CRM status. When tumor involvement of the fascia as revealed by MRI (minimum distance 1mm) is used as the criterion for initiating neoadjuvant treatment, chemoradiation is recommended less frequently (3). However, there are concerns about the reliability of MRI, because false-negative predictions of CRM involvement were observed in 5-10% of patients (4), which constitutes undertreatment in these cases. Otherwise the positive predictive value for CRM involvement ranged between 20% and 89% (5), suggesting overtreatment as the result of a CRM-based decision process for neoadjuvant chemoradiation.A recent review concluded that the evidence regarding the reliability of MRI in predicting CRM involvement is insufficient (5). However, many of the previous investigations included irradiated patients (6-12) and it is known that the value of MRI restag...

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“…An advantage of MRI is the ability to delineate the tumour and its relationship to the mesorectal fascia. High-resolution MRI predicted mesorectal fascia involvement with 92% agreement [14]. According to the results of the prospective MECURY trial, high-resolution MRI has sensitivity of 94% and specificity of 92% for predicting negative circumferential margins (CRM) after surgery [15].…”

Section: Tumour Diagnosis and Stagingmentioning

confidence: 99%

“…After dividing the inferior mesenteric vein under the pancreas and the inferior mesenteric artery (IMA), complete mobilization is achieved by lateral dissection and mobilization of the splenic flexure and the descending colon and freeing the greater omentum from the transverse colon. Dissection will proceed with medial dissection of distal sigmoid and rectum [2][3][4][5][6][7][8][9][10][11][12][13][14][15].…”

Section: (100% [Strong Consensus]; Gor C: 100% [Strong Consensus])mentioning

confidence: 99%

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

et al. 2011

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Background The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. Methods An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. Results Laparoscopic surgery for extraperitoneal (midand low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not

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Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging

Abstract: High-resolution MRI of the rectum allows preoperative identification of important surgical and pathological prognostic risk factors. This may allow both better selection and assessment of patients undergoing preoperative therapy.

Cited by 650 publications

References 23 publications

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

Preoperative radiotherapy combined with 5 days per week capecitabine chemotherapy in locally advanced rectal cancer

Rectal Cancer: MR imaging of the mesorectal fascia and effect of chemoradiation on assessment of tumor involvement

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

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