水囊扩张法3D经直肠腔内超声在低位直肠癌术前分期中的应用

目的评价水囊扩张法3D经直肠腔内超声（ERUS）检查在低位直肠癌术前分期中的灵敏度和特异度。 方法采用水囊扩张法对海军军医大学附属长海医院收治的72例低位直肠癌患者行术前腔内超声检查,进行术前T分期,并与手术后病理T分期进行比较,分析超声术前分期的灵敏度、特异度、过深分期和过浅分期百分比。 结果共72例患者入组,其中超声T1期直肠癌16例,T2期直肠癌23例,T3期直肠癌25例,T4期直肠癌8例。术前腔内超声诊断早期直肠癌T1、T2、T3、T4期诊断灵敏度和特异度分别为93.3%和96.5%,87.0%和93.9%,84.0%和91.5%,71.4%和95.4%。过深分期百分比为5.6%,过浅分期百分比为11.1%。 结论水囊扩张法3D经直肠腔内超声检查对低位直肠癌术前分期和手术治疗具有重要的指导意义。     

内镜下全层切除术联合新辅助放化疗治疗局部进展期低位直肠癌1例（含视频）

本文报道了1例内镜下全层切除术联合新辅助放化疗治疗局部进展期低位直肠癌的病例。1例保肛意愿强烈的局部进展期低位直肠癌患者行新辅助放化疗达近临床完全缓解后，进一步行内镜下全层切除术切除病灶。病理示直肠腺癌，浸润肠壁深肌层，局部浸润深肌层外结缔组织。术后患者进一步追加辅助放疗，随访至今肛门功能良好，无复发转移征象。     

直肠癌腔内超声分期的诊断价值及其与TNM分期关系

目的:探讨经直肠腔内超声(TRUS)对直肠癌术前分期的诊断价值及其与TNM分期的关系.方法:对65例经病理证实为直肠癌的患者术前进行TRUS检查, 记录癌肿浸润周径, 同时采用TNM分期标准进行分期, 并与术后TNM分期进行对照.结果:65例直肠癌术前TRUS检查总的诊断准确率为86.15%, T1-T4期TRUS诊断准确性分别为 93.85%、87.69%、90.77%及100%, 直肠癌癌肿浸润周径与TNM分期间呈正相关(r =0.89, P <0.01), 结合直肠癌癌肿浸润周径程度可以使直肠癌术前分期总的诊断准确率明显提高(95.38%).结论:TRUS检查对于直肠癌术前分期有较高的诊断准确性, 有助于制定合理的治疗方案,结合直肠癌组织浸润周径可提高术前分期诊断准确性.     

局部进展期直肠癌新辅助放化疗后病理完全缓解临床相关因素探究

目的探讨局部进展期直肠癌新辅助放化疗后病理完全缓解（pCR）的临床相关因素。 方法回顾性分析2013年1月至2018年5月期间四川省肿瘤医院肠道外科病区收治的117例局部进展期直肠癌新辅助放化疗及手术的临床资料,采用单因素分析及logistic二分类多因素回归分析法研究pCR的临床相关因素。 结果117例患者全部完成新辅助放化疗及根治手术,其中19例（16.24%）患者达到pCR。单因素分析结果显示,性别为女性（P=0.024）,年龄较年轻（P=0.042）,放疗前CEA<5 ug/L（P=0.015）,无吸烟史（P=0.008）,无饮酒史（P=0.037）,肿瘤距肛缘距离大于6 cm（P=0.048）和局部进展期直肠癌新辅助放化疗后高pCR率有关。多因素回归分析结果显示,放疗前CEA<5 ug/L（P=0.039）和肿瘤距肛缘距离>6 cm（P=0.043）是影响局部进展期直肠癌新辅助放化疗后pCR率的独立因素。 结论放疗前CEA水平和肿瘤距肛缘距离是影响局部进展期直肠癌新辅助放化疗后pCR率的相关临床因素。     

超声双重造影在结直肠癌诊断及分期评估中的应用进展

结直肠癌是消化道常见的恶性肿瘤之一,其发病率和死亡率均较高。TNM分期是指导临床制定结直肠癌治疗方案及判断预后的关键,尤其是T分期。结直肠癌筛查与分期评估的方法有多种,如电子肠镜、MRI、CT、超声等,但均存在一定不足之处。超声双重造影（DCEUS）是近年发展起来的一种无创性超声成像技术,是在经直肠腔内灌注超声造影检查基础上联合静脉超声造影检查,能够清晰显示肠壁各层次结构,实时动态地观察病变组织的微血流灌注情况,从而更有助于结直肠癌的诊断及分期评估。目前,DCEUS在结直肠良恶性病变鉴别诊断和结直肠癌T分期评估、新辅助放化疗后再分期评估以及环周切缘评估中均具有一定的临床价值。未来DCEUS有潜力成为诊断结直肠癌的常规影像学检查方法之一,并在临床中普及应用。     

超声内镜在直肠癌新辅助治疗后再分期的应用价值研究

目的探讨超声内镜在直肠癌新辅助放化疗后再分期的准确性。方法61例初诊直肠癌患者纳入研究,新辅助治疗后行超声内镜分期,并与手术后病理分期进行比较。结果放化疗后EUS对直肠癌T分期的总准确率为59．0％（36／61）,36．1％（22／61）的病例分期过高,4．9％（3／61）的病例分期过低。EUS对直肠癌N分期准确率为68．9％（42／61）,14．7％（9／61）的病例分期过高,16．4％（10／61）的病例分期过低。结论EUS对新辅助治疗后的直肠癌进行再分期的准确率降低。     

微探头联合环扫内镜超声对直肠癌术前分期的价值

目的 评价微探头超声联合环扫内镜超声检查对直肠癌术前分期的特异性、敏感性和准确性以及判断其对直肠癌治疗方案选择的价值.方法 对2007年8月-2008年8月60例术前直肠癌患者行微探头和环扫超声内镜联合探查.参照TNM分期标准进行分期诊断,并与MRI、手术后组织病理学结果对比,总结EUS分期对治疗方案选择的参考价值.结果 在60例直肠癌患者中,EUS分期T1期4例,T2期18例,T3期30例,T4期8例,存在7例分期过度和4例分期不足;MRI分期T1期1例,T2期18例,T3期30例,T4期10例,存在14例分期过度和3例分期不足.微探头超声内镜结合环扫型超声内镜对直肠癌T分期诊断综合准确率为81.67%(49/60),N分期的准确率为78.33%,敏感性和特异性为71.43%和91.03%;MRI对直肠癌T分期准确率为71.67%(43/60),周围淋巴结转移诊断的准确率为83.33%,敏感性和特异性为85.71%和86.96%.结论 微探头联合环扫内镜超声检查是一有效估计直肠癌肠壁浸润深度并对其进行TN分期的方法,且操作简便、痛苦小、诊断准确率较高.     

CEA在评估直肠癌新辅助放化疗后肿瘤退缩中的意义

目的探讨局部晚期直肠癌术前新辅助放化疗疗效的预测因素,以指导直肠癌的个体化治疗。 方法回顾性分析南京医科大学第一附属医院2014年3月至2015年3月间收治的28例局部进展期直肠癌患者的临床病理资料,利用化学发光法检测新辅助放化疗前、后直肠癌患者血清癌胚抗原（carcino embryonie antigen,CEA）水平,以放化疗后肿瘤TNM分期降期与否和肿瘤消退程度（肿瘤长径）作为同步放化疗疗效的判断标准,分析CEA检测值的变化与直肠癌患者新辅助治疗疗效及预后等临床特征之间的关系。 结果病理完全缓解组(pathologic complete response,pCR)组与非pCR组患者,CEA的水平在新辅助治疗前后无统计学差异(p=0.069),新辅助治疗后,CEA的下降程度在两组中未见差异（p=0.827）。经新辅助治疗后肿瘤长径退缩显著组,CEA下降程度也较显著,CEA下降≥50%组内,新辅助治疗后肿瘤长径退缩≥25%的患者占70.6%,CEA下降<50%组内,此部分患者仅占54.6%。 结论新辅助放化疗后CEA明显下降的患者其肿瘤退缩更显著,提示CEA可能作为一项直观的评估直肠癌新辅助放化疗的疗效指标。     

超声内镜在直肠癌新辅助治疗后再分期的应用价值研究

目的 探讨超声内镜在直肠癌新辅助放化疗后再分期的准确性.方法 61例初诊直肠癌患者纳入研究,新辅助治疗后行超声内镜分期,并与手术后病理分期进行比较.结果放化疗后EUS对直肠癌T分期的总准确率为59.0%(36/61),36.1%(22/61)的病例分期过高,4.9%(3/61)的病例分期过低.EUS对直肠癌N分期准确率为68.9%(42/61),14.7%(9/61)的病例分期过高,16.4%(10/61)的病例分期过低.结论 EUS对新辅助治疗后的直肠癌进行再分期的准确率降低.     

超声内镜在直肠癌新辅助治疗后再分期的应用价值研究

目的 探讨超声内镜在直肠癌新辅助放化疗后再分期的准确性.方法 61例初诊直肠癌患者纳入研究,新辅助治疗后行超声内镜分期,并与手术后病理分期进行比较.结果放化疗后EUS对直肠癌T分期的总准确率为59.0%(36/61),36.1%(22/61)的病例分期过高,4.9%(3/61)的病例分期过低.EUS对直肠癌N分期准确率为68.9%(42/61),14.7%(9/61)的病例分期过高,16.4%(10/61)的病例分期过低.结论 EUS对新辅助治疗后的直肠癌进行再分期的准确率降低.     

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

It is essential in treating rectal cancer to have adequate preoperative imaging,as accurate staging can influence the management strategy,type of resection,and candidacy for neoadjuvant therapy.In the last twenty years,endorectal ultrasound(ERUS) has become the primary method for locoregional staging of rectal cancer.ERUS is the most accurate modality for assessing local depth of invasion of rectal carcinoma into the rectal wall layers(T stage) .Lower accuracy for T2 tumors is commonly reported,which could ...     

Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer

AIM： To compare the diagnostic accuracy of pelvic phased-array magnetic resonance imaging （MRI） and endorectal ultrasonography （ERUS） in the preoperative staging of rectal carcinoma.
METHODS： Thirty-four patients （15 males, 19 females） with ages ranging between 29 and 75 who have biopsy proven rectal tumor underwent both MRI and ERUS examinations before surgery. All patients were evaluated to determine the diagnostic accuracy of depth of transmural tumor invasion and lymph node metastases. Imaging results were correlated with histopathological findings regarded as the gold standard and both modalities were compared in terms of predicting preoperative local staging of rectal carcinoma.
RESULTS： The pathological T stage of the tumors was： pT1 in 1 patient, pT2 in 9 patients, pT3 in 21 patients and pT4 in 3 patients. The pathological N stage of the tumors was： pN0 in 19 patients, pN1 in 9 patients and pN2 in 6 patients. The accuracy of T staging for MRI was 89.70% （27 out of 34）. The sensitivity was 79.41% and the specificity was 93.14%. The accuracy of T staging for ERUS was 85.29% （24 out of 34）. The sensitivity was 70.59% and the specificity was 90.20%. Detection of lymph node metastases using phased-array MRI gave an accuracy of 74.50% （21 out of 34）. The sensitivity and specificity was found to be 61.76% and 80.88%, respectively. By using ERUS in the detection of lymph node metastases, an accuracy of 76.47% （18 out of 34） was obtained. The sensitivity and specificity were found to be 52.94% and 84.31%, respectively.
CONCLUSION： ERUS and phased-array MRI are complementary methods in the accurate preoperative staging of rectal cancer. In conclusion, we can state that phased-array MRI was observed to be slightly superior in determining the depth of transmural invasion （T stage） and has same value in detecting lymph node metastases （N stage） as compared to ERUS.     

Limitations of Early Rectal Cancer Nodal Staging may Explain Failure after Local Excision

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. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available.     

Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy

OBJECTIVES: Endoscopic ultrasound (EUS) provides important information in the initial staging of patients with rectal cancer. Preoperative combined modality chemotherapy and radiation (neoadjuvant therapy) for patients with locally advanced rectal cancer may reduce local recurrence and improve survival. The accuracy of EUS restaging of rectal cancer after chemoradiation has not been extensively studied and its usefulness is unclear. The aim of this study was to verify the accuracy of EUS in staging rectal cancer after neoadjuvant chemoradiation in a large cohort of patients. METHODS: EUS staging was performed before and after concurrent 5-fluorouracil and hyperfractionated radiotherapy in 82 patients with recently diagnosed locally advanced rectal cancer. All patients underwent subsequent surgical resection and complete pathologic staging. RESULTS: After chemoradiation, 16 patients (20%) had no residual disease at pathologic staging. (T0N0). However, EUS correctly predicted complete response to chemoradiation in only 10 of 16 patients (63%). Overall accuracy of EUS post chemoradiation for pathologic T-stage was only 48%. Fourteen percent were understaged and 38% overstaged. EUS accuracy for N-stage was 77%. The T-category was correctly staged before surgery in 23 of the 56 responders (41%) and in 16 of 24 nonresponders (67%). EUS was unable to accurately distinguish postradiation changes from residual tumor. CONCLUSION: EUS staging of rectal cancer after chemoradiation is inaccurate, especially in the group of patients with visual and EUS evidence of response. Its routine use for staging purposes after neoadjuvant chemoradiation for rectal cancer should be discouraged.     

Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve?

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.     

Adjuvant therapy sparing in rectal cancer achieving complete response after chemoradiation

AIM: To evaluate the long-term results of conventional chemoradiotherapy and laparoscopic mesorectal excision in rectal adenocarcinoma patients without adjuvant therapy.METHODS: Patients with biopsy-proven adenocarcinoma of the rectum staged cT3-T4 by endoscopic ultrasound or magnetic resonance imaging received neoadjuvant continuous infusion of 5-fluorouracil for five weeks and concomitant radiotherapy. Laparoscopic surgery was planned after 5-8 wk. Patients diagnosed with ypT0N0 stage cancer were not treated with adjuvant therapy according to the protocol. Patients with ypT1-2N0 or ypT3-4 or N+ were offered 5-fluorouracil-based adjuvant treatment on an individual basis. An external cohort was used as a reference for the findings.RESULTS: One hundred and seventy six patients were treated with induction chemoradiotherapy and 170 underwent total mesorectal excision. Cancer staging of ypT0N0 was achieved in 26/170 (15.3%) patients. After a median follow-up of 58.3 mo, patients with ypT0N0 had five-year disease-free and overall survival rates of 96% (95%CI: 77-99) and 100%, respectively. We provide evidence about the natural history of patients with localized rectal cancer achieving a complete response after preoperative chemoradiation. The inherent good prognosis of these patients will have implications for clinical trial design and care of patients.CONCLUSION: Withholding adjuvant chemotherapy after complete response following standard neoadjuvant chemoradiotherapy and laparoscopic mesorectal excision might be safe within an experienced multidisciplinary team.     

Stage and size using magnetic resonance imaging and endosonography in neoadjuvantly-treated rectal cancer

AIM: To assess the stage and size of rectal tumours using 1.5 Tesla (1.5T) magnetic resonance imaging (MRI) and three-dimensional (3D) endosonography (ERUS). METHODS: In this study, patients were recruited in a phaseⅠ/Ⅱ trial of neoadjuvant chemotherapy for biopsy-proven rectal cancer planned for surgical resection with or without preoperative radiotherapy. The feasibility and accuracy of 1.5T MRI and 3D ERUS were compared with the histopathology of the fixed surgical specimen (pathology) to determine the stage and size of the rectal cancer before and after neoadjuvant chemotherapy. A Philips Intera 1.5T with a cardiac 5-channel synergy surface coil was used for the MRI, and a B-K Medical Falcon 2101 EXL 3D-Probe was used at 13 MHz for the ERUS. Our hypothesis was that the staging accuracy would be the same when using MRI, ERUS and a combination of MRI and ERUS. For the combination, MRI was chosen for the assessment of the lymph nodes, and ERUS was chosen for the assessment of perirectal tissue penetration. The stage was dichotomised into stageⅠ and stage Ⅱ or greater. The size was measured as the supero-inferior length and the maximal transaxial area of the tumour. RESULTS: The staging feasibility was 37 of 37 for the MRI and 29 of 36 for the ERUS, with stenosis as a limiting factor. Complete sets of investigations were available in 18 patients for size and 23 patients for stage. The stage accuracy by MRI, ERUS and the combination of MRI and ERUS was 0.65, 0.70 and 0.74, respectively, before chemotherapy and 0.65, 0.78 and 0.83, respectively, after chemotherapy. The improvement of the post-chemotherapy staging using the combination of MRI and ERUS compared with the staging using MRI alone was significant (P = 0.046). The post-chemotherapy understaging frequency by MRI, ERUS and the combination of MRI and ERUS was 0.18, 0.14 and 0.045, respectively, and these differences were non-significant. The measurements of the supero-inferior length by ERUS compared with MRI were within 1.96 standard deviations of     

Endorectal ultrasound does not reliably identify patients with uT3 rectal cancer who can avoid neoadjuvant chemoradiotherapy

Purpose

Neoadjuvant chemoradiation (NCRT) may be avoided in some patients with T3-staged rectal cancer undergoing radical resection. We aimed to evaluate the accuracy of endorectal ultrasound (ERUS) in the nodal staging of uT3 tumors and hence the decision for administration of NCRT.

Methods

Patients with uT3-staged rectal cancer who underwent proctectomy were retrospectively identified. The accuracy of ERUS for detecting nodal involvement was determined for patients who did not undergo NCRT. In order to evaluate the impact of use of NCRT, oncologic outcomes, functional outcomes, and quality of life (QOL) were compared for patients who received NCRT (group A) and those who did not (group B).

Results

For 384 patients who were included, ERUS overstaging rate for nodal involvement was 6.3 % while understaging rate was 23.2 %. For the 289 patients in group A and 95 in group B, Kaplan–Meier analysis showed similar 5-year local recurrence rates (3.5 %), overall survival (76.9 vs 75.6 %), and disease-free survival (87.9 vs 88.1 %). Node positivity on final pathology was however associated with worse 5-year local recurrence (9.3 vs 4.3 %). For patients undergoing restorative resection, NCRT was associated with worse functional outcomes but QOL was similar.

Conclusions

ERUS identification of nodal involvement used as a criterion for NCRT carries a greater risk for undertreatment than overtreatment. Undertreatment adversely affects oncologic outcomes. While there is functional impairment related to NCRT, its effect on QOL is non-significant. The decision for omitting neoadjuvant chemoradiation for uT3 rectal cancer should hence not be based on ERUS nodal staging alone.     

Interpretation of Magnetic Resonance Imaging for Locally Advanced Rectal Carcinoma After Preoperative Chemoradiation Therapy

PURPOSE: Neoadjuvant concomitant chemoradiotherapy has been used in cases of locally advanced rectal cancer to preserve sphincter function, decrease local recurrence, and improve survival. Preoperative staging is essential for planning and providing optimal therapy. The purpose of this study is to determine the accuracy of staging with magnetic resonance imaging and to define any factors that interfere in interpretation of images obtained after preoperative chemoradiation therapy.METHODS: Thirty-six patients with biopsy-proven, locally advanced rectal cancer were treated with preoperative concomitant 5-fluorouracil-based chemotherapy and radiation, followed six to eight weeks later by radical surgery. Preoperative magnetic resonance images were reinterpreted by one radiologist and the results compared with histopathologic staging.RESULTS: T-level downstaging occurred in 10 of 36 patients (28 percent), and N-level downstaging occurred in 29 of 36 patients (80 percent) after completion of chemoradiation therapy. Pathologic complete remission after chemoradiotherapy occurred in five patients (12 percent). Of the 36 patients, 17 (47 percent) were overstaged and 2 (6 percent) were understaged in T-level, whereas 10 patients (28 percent) were overstaged and 3 patients (8 percent) were understaged in N-level. The accuracy of magnetic resonance imaging for determining depth of wall invasion was 47 percent, with 64 percent accuracy for nodal staging.CONCLUSIONS: Magnetic resonance imaging is commonly used in staging of pelvic malignancies because of its fine resolution, but chemoradiotherapy may decrease its accuracy. Thickening of the rectal wall after radiation by marked fibrosis, and peritumoral infiltration of inflammatory cells and vascular proliferation may contribute to overestimation of stage. By contrast, pathologic residual cancer beneath normal mural structure after chemoradiation therapy may result in understaging of rectal cancer.Presented at the Scientific Meeting of the Taiwan Surgical Association, Taipei, Taiwan, March 27 to 28, 2004.