Local staging of rectal cancer: a review of imaging

During the past decades the management of patients with rectal cancer has substantially changed, with a significant reduction in local recurrence rates following the introduction of better imaging, better surgery, and more efficient neoadjuvant therapy. This review discusses the clinically relevant information radiologists should know on staging of rectal cancer patients. The crucial role of the radiologist in patient management is explained. Furthermore, the evidence for the use of magnetic resonance imaging (MRI) in staging and restaging of rectal cancer patients as well as the main features that need to be evaluated when interpreting rectal cancer MRI are given. New diagnostic challenges as a result of new treatment options are also discussed. J. Magn. Reson. Imaging 2011;33:1012-1019. (c) 2011 Wiley-Liss, Inc

Pretherapy imaging of rectal cancers: ERUS or MRI?

ERUS and MRI should be seen more as complementary rather than competitive techniques. Each has its own strengths and weaknesses. ERUS is better in showing the tumor extent in small superficial tumors, whereas MRI is superior in imaging the more advanced tumors. The choice of imaging technique depends also on the amount of information that is required for choosing certain treatment strategies, like the distance to the mesorectal fascia for a short course of preoperative radiotherapy. For lymph node imaging, both techniques are at present only moderately accurate, although this could change with advances in new MR techniques

Diffusion-weighted MR imaging in primary rectal cancer staging demonstrates but does not characterise lymph nodes

OBJECTIVES: To evaluate the performance of diffusion-weighted MRI (DWI) detection of lymph nodes and for differentiating between benign and nodes during primary rectal cancer staging. METHODS: Twenty-one patients underwent 1.5-T MRI followed by surgery (+/- preoperative 5 x 5 Gy). consisted of T2-weighted MRI, DWI (b0, 500, 1000), and 3DT1-weighted MRI 1-mm isotropic voxels. The latter was used for accurate detection and histological validation of nodes. Two independent readers analysed the intensity on DWI and measured the mean apparent diffusion coefficient each node (ADCnode) and the ADC of each node relative to the mean tumour (ADCrel). RESULTS: DWI detected 6 % more nodes than T2W-MRI. The signal was not accurate for the differentiation of metastatic nodes (AUC 0.45- Interobserver reproducibility for the nodal ADC measurements was 0.93). Mean ADCnode was higher for benign than for malignant nodes (1.15 vs. 1.04 +/- 0.22 *10-3 mm2/s), though not statistically significant (P Area under the ROC curve/sensitivity/specificity for the assessment of nodes were 0.64/67 %/60 % for ADCnode and 0.67/75 %/61 % for ADCrel. DWI can facilitate lymph node detection, but alone it is not reliable differentiating between benign and malignant lymph nodes. KEY POINTS: * Diffusion-weighted (DW) magnetic resonance imaging (MRI) offers new in rectal cancer. * DW MRI demonstrates more lymph nodes than standard T2-weighted MRI. * Visual DWI assessment does not discriminate between metastatic nodes. * Apparent diffusion coefficients do not discriminate benign and metastatic nodes

Preoperative assessment of the circumferential margin in rectal cancer is more informative in treatment planning than the T stage.

Preventing local recurrence in rectal cancer means achieving a free circumferential resection margin (CRM) through an optimal combination of surgery, radiotherapy and chemotherapy. This requires a differentiation between primary resectable and locally advanced cancers. The T staging used, while being a powerful marker of prognosis, has two major downsides. First, accuracy of preoperative predictions of the T stage is unacceptably low. Second, a T3 tumor can be either primary resectable or locally advanced. A review of the literature was performed to establish the value of the CRM as the preferred preoperative staging classification, and to establish the feasibility of predicting the CRM using modern day, high-resolution imaging techniques. We advocate using the CRM as preoperative staging classification. Magnetic resonance imaging and multislice computed tomography offer an accurate pre-operative prediction of the CRM, and staging by means of predicted CRM offers the ideal combination of accuracy and clinical relevance

Preoperative assessment of the circumferential margin in rectal cancer is more informative in treatment planning than the T stage.

Contains fulltext : 50061.pdf (publisher's version ) (Closed access)Preventing local recurrence in rectal cancer means achieving a free circumferential resection margin (CRM) through an optimal combination of surgery, radiotherapy and chemotherapy. This requires a differentiation between primary resectable and locally advanced cancers. The T staging used, while being a powerful marker of prognosis, has two major downsides. First, accuracy of preoperative predictions of the T stage is unacceptably low. Second, a T3 tumor can be either primary resectable or locally advanced. A review of the literature was performed to establish the value of the CRM as the preferred preoperative staging classification, and to establish the feasibility of predicting the CRM using modern day, high-resolution imaging techniques. We advocate using the CRM as preoperative staging classification. Magnetic resonance imaging and multislice computed tomography offer an accurate pre-operative prediction of the CRM, and staging by means of predicted CRM offers the ideal combination of accuracy and clinical relevance

Nierfunctieverlies bij diep infiltratieve endometriose: tijdige herkenning van ureterobstructie is geboden [Loss of renal function due to deep infiltrating endometriosis; a complicated consideration in women who wish to have children]

Three nulliparous women, aged 39, 34 and 26 years, who were treated for fertility problems and who were affected by endometriosis, presented with ureteral obstruction caused by deep infiltrating endometriosis. The first two patients had complete unilateral loss of kidney function at the time of diagnosis. They chose to have fertility treatment first and both became pregnant. The third patient still had 24% renal function in the affected left kidney. She was treated by complete surgical resection of the endometriosis and reimplantation of the ureter. Ureteral obstruction is a rare, but serious, complication of deep infiltrating endometriosis. Timely recognition is important, since delay results in unnoticed loss of renal function. Clinical investigation for endometriosis of the posterior vaginal fornix is recommended for all patients with chronic abdominal pain, severe dysmenorrhoea or deep dyspareunia. On diagnosis of deep infiltrating endometriosis, further examination is necessary to detect possible ureteral obstruction and consequent hydronephrosis, which can be demonstrated by ultrasound. MRI is of value to map the extent of disease, which is usually multi-focal. Surgery to relieve ureteral obstruction and remove all endometriotic lesions is the treatment of choice if the kidney is still functional