Management Of Rectal Cancer Patients Research Articles

471 Accuracy of Preoperative MRI for Rectal Cancer: A Retrospective Study at a District General Hospital

Abstract Aim To investigate the accuracy of preoperative MRI for rectal cancer in the form of sensitivity, specificity, positive predictive value and negative predictive value. Method The retrospective study included a cohort of 47 patients of rectal cancer from April 2017 to March 2022 who were treated with upfront surgery. With histopathology taken as standard the accuracy of preoperative MRI was calculated. Results The records of 47 rectal cancer patients were analysed who were offered primary surgery. The sensitivity and specificity of MRI for T1-T4 were 60%, 19%, 94% and 100% and 97%, 84%, 48% and 100% respectively. The sensitivity and specificity of N0- N2 staging were 46%, 57% and 50% and 61%, 53% and 95% respectively. The positive predictive value and negative predictive value of MRI for T and N staging were 69%, 85%, 44% and 77% respectively. Conclusions In our study, the results were not at par with other national and international studies. MRI is a useful tool for planning management of rectal cancer patients. The accurate preoperative staging is very important for planning the management of these patients.

Develop and validate a radiomics space-time model to predict the pathological complete response in patients undergoing neoadjuvant treatment of rectal cancer: an artificial intelligence model study based on machine learning

ObjectiveIn this study, we aimed to investigate the predictive efficacy of magnetic resonance imaging (MRI) radiomics features at different time points of neoadjuvant therapy for rectal cancer in patients with pathological complete response (pCR). Furthermore, we aimed to develop and validate a radiomics space–time model (RSTM) using machine learning for artificial intelligence interventions in predicting pCR in patients.MethodsClinical and imaging data of 83 rectal cancer patients were retrospectively analyzed, and the patients were classified as pCR and non-pCR patients according to their postoperative pathological results. All patients received one MRI examination before and after neoadjuvant therapy to extract radiomics features, including pre-treatment, post-treatment, and delta features. Delta features were defined by the ratio of the difference between the pre- and the post-treatment features to the pre-treatment feature. After feature dimensionality reduction based on the above three feature types, the RSTM was constructed using machine learning methods, and its performance was evaluated using the area under the curve (AUC).ResultsThe AUC values of the individual basic models constructed by pre-treatment, post-treatment, and delta features were 0.771, 0.681, and 0.871, respectively. Their sensitivity values were 0.727, 0.864, and 0.909, respectively, and their specificity values were 0.803, 0.492, and 0.656, respectively. The AUC, sensitivity, and specificity values of the combined basic model constructed by combining pre-treatment, post-treatment, and delta features were 0.901, 0.909, and 0.803, respectively. The AUC, sensitivity, and specificity values of the RSTM constructed using the K-Nearest Neighbor (KNN) classifier on the basis of the combined basic model were 0.944, 0.871, and 0.983, respectively. The Delong test showed that the performance of RSTM was significantly different from that of pre-treatment, post-treatment, and delta models (P < 0.05) but not significantly different from the combined basic model of the three (P > 0.05).ConclusionsThe RSTM constructed using the KNN classifier based on the combined features of before and after neoadjuvant therapy and delta features had the best predictive efficacy for pCR of neoadjuvant therapy. It may emerge as a new clinical tool to assist with individualized management of rectal cancer patients.

International survey among surgeons on the perioperative management of rectal cancer.

Several pivotal studies and international guidelines on the perioperative management of rectal cancer have been published. However, little is known about the current state of perioperative management of rectal cancer patients in clinical practice worldwide. An online survey including 13 questions focusing on key topics related to the perioperative management of patients with rectal cancer was conducted among colorectal surgeons registered within the database of the Research Institute Against Digestive Cancer (IRCAD). A total of 535 respondents from 89 countries participated in the survey. Most surgeons worked in the European region (40.9%). Two hundred and fifty-four respondents (47.5%) performed less than 25% of surgical procedures laparoscopically. The most commonly used definition of the upper limit of the rectum was a fixed distance from the anal verge (23.4%). Magnetic resonance imaging was used to define the upper limit of the rectum by 258 respondents (48.2%). During total mesorectal excision (TME), 301 respondents (56.3%) used a high-tie technique. The most commonly constructed anastomosis was an end-to-end anastomosis (68.2%) with the majority of surgeons performing a leak test intraoperatively (88.9%). A total of 355 respondents (66.4%) constructed a diverting ostomy, and the majority of these surgeons constructed an enterostomy (82%). A total of 208 respondents (39.3%) closed a stoma within 8weeks. Lastly, 135 respondents (25.2%) introduced a solid diet on postoperative day 1. There is considerable heterogeneity in the perioperative management of rectal cancer patients worldwide with several discrepancies between current international practice and recommendations from international guidelines. To achieve worldwide standardization in rectal cancer care, further research is needed to elucidate the cause of this heterogeneity and find ways of improved implementation of best practice recommendations.

How can I Start an Multidisciplinary Team for Management of Rectal Cancer Patients? Analysis of the Feasibility of Using American National Accreditation Program for Rectal Cancer Patients Standards in a Low-Income Country Hospital

How can I Start an Multidisciplinary Team for Management of Rectal Cancer Patients? Analysis of the Feasibility of Using American National Accreditation Program for Rectal Cancer Patients Standards in a Low-Income Country Hospital

“Watch and wait” strategy (active dynamic follow-up) in the management of rectal cancer patients with a complete clinical response

Background. Currently available chemoradiotherapy regimens for distal rectal cancer often ensure complete regression of the tumor and lymph node lesions. Therefore, patients with a complete clinical response can be managed with a “watch and wait” (ww) strategy.Objective: to evaluate 2-year overall and progression-free survival in patients with local and locally advanced rectal cancer with a complete clinical response who were managed with the ww strategy.Materials and methods. we performed retrospective analysis of treatment outcomes in patients with newly diagnosed, histologically verified, stage II–III, mrT1–2n1–2m0, T3–4n0–2m0 (within 0–10 cm of the anal verge), and mrT2n0m0 (within 0–5 cm of the anal verge) rectal cancer who had demonstrated complete clinical response to chemoradiotherapy. mandard tumor regression grade (TRg1–2) (assessed using magnetic resonance imaging of the pelvis) and palpatory/visual signs of residual tumor (assessed by digital examination and colonoscopy) were the main parameters evaluated. Overall and disease-free survival was analyzed using the Kaplan–meier method.Results. Twenty-seven patients with a complete clinical response were assigned to the ww group. mRI scans of the pelvis demonstrated that 5 patients (18.5 %) had TRg1, whereas 22 patients (81.5 %) had TRg2. T-downstaging after therapy was observed in 21 participants (77.7 %). n-downstaging was registered in all 14 patients (100 %) with regional lymph nodes affected. median follow-up time was 41 months (range: 25–114 months). Two individuals (7.4 %) developed progressive disease. Both of them had lengthy tumors as demonstrated by digital examination, colonoscopy, and magnetic resonance imaging; they immediately underwent radical surgery. The two-year overall and disease-free survival rates were 100 % and 92.6 %, respectively. Conclusion. The ww strategy with active dynamic follow-up is safe for the management of patients with local and locally advanced middle and lower rectal cancer, provided that inclusion/exclusion criteria are adhered to and patients are carefully followed-up in specialized centers.

Role of dynamic perfusion magnetic resonance imaging in patients with local advanced rectal cancer.

BACKGROUNDThe management of rectal cancer patients is mainly based on the use of the magnetic resonance imaging (MRI) technique as a diagnostic tool for both staging and restaging. After treatment, to date, the evaluation of complete response is based on the histopathology assessment by using different tumor regression grade (TRG) features (e.g., Dworak or Mandard classifications). While from the radiological point of view, the main attention for the prediction of a complete response after chemotherapy treatment focuses on MRI and the potential role of diffusion-weighted images and perfusion imaging represented by dynamic-contrast enhanced MRI. The main aim is to find a reliable tool to predict tumor response in comparison to histopathologic findings.AIMTo investigate the value of dynamic contrast-enhanced perfusion-MRI parameters in the evaluation of the healthy rectal wall and tumor response to chemo-radiation therapy in patients with local advanced rectal cancer with histopathologic correlation.METHODSTwenty-eight patients with biopsy-proven rectal adenocarcinoma who underwent a dynamic contrast-enhanced MR study performed on a 1.5T MRI system (Achieva, Philips), before (MR1) and after chemoradiation therapy (MR2), were enrolled in this study. The protocol included T1 gadolinium enhanced THRIVE sequences acquired on axial planes. A dedicated workstation was used to generate color permeability maps. Region of interest was manually drawn on tumor tissue and normal rectal wall, hence the following parameters were calculated and statistically analyzed: Relative arterial enhancement (RAE), relative venous enhancement (RVE), relative late enhancement (RLE), maximum enhancement (ME), time to peak and area under the curve (AUC). Perfusion parameters were related to pathologic TRG (Mandard's criteria; TRG1 = complete regression, TRG5 = no regression).RESULTSTen tumors (36%) showed complete or subtotal regression (TRG1-2) at histology and classified as responders; 18 tumors (64%) were classified as non-responders (TRG3-5). Perfusion MRI parameters were significantly higher in the tumor tissue than in the healthy tissue in MR1 (P < 0.05). At baseline (MR1), no significant difference in perfusion parameters was found between responders and non-responders. After chemo-radiation therapy, at MR2, responders showed significantly (P < 0.05) lower perfusion values [RAE (%) 54 ± 20; RVE (%) 73 ± 24; RLE (%): 82 ± 29; ME (%): 904 ± 429] compared to non-responders [RAE (%): 129 ± 45; RVE (%): 154 ± 39; RLE (%): 164 ± 35; ME (%): 1714 ± 427]. Moreover, in responders group perfusion values decreased significantly at MR2 [RAE (%): 54 ± 20; RVE (%): 73 ± 24; RLE (%): 82 ± 29; ME (%): 904 ± 429] compared to the corresponding perfusion values at MR1 [RAE (%): 115 ± 21; RVE (%): 119 ± 21; RLE (%): 111 ± 74; ME (%): 1060 ± 325]; (P < 0.05). Concerning the time-intensity curves, the AUC at MR2 showed significant difference (P = 0.03) between responders and non-responders [AUC (mm2 × 10-3) 121 ± 50 vs 258 ± 86], with lower AUC values of the tumor tissue in responders compared to non-responders. In non-responders, there were no significant differences between perfusion values at MR1 and MR2.CONCLUSIONDynamic contrast perfusion-MRI analysis represents a complementary diagnostic tool for identifying vascularity characteristics of tumor tissue in local advanced rectal cancer, useful in the assessment of treatment response.

Multidisciplinary Conference and Clinical Management of Rectal Cancer

Presentation of rectal cancer cases at a colorectal cancer multidisciplinary conference (CRC-MDC) is a required standard for the newly formed National Accreditation Program for Rectal Cancer administered by the Commission on Cancer. The aim of this study was to determine the frequency and manner in which CRC-MDC changed the management of rectal cancer patients at a tertiary academic center. All rectal cancer cases presented at a weekly CRC-MDC between July 2015 and June 2016 were prospectively included. Patient demographics and clinical information were recorded. The presenting physician completed a uniform written questionnaire outlining any changes in management as a result of the discussion. There were 408 rectal cancer cases included, and survey responses were obtained for 371 (91%). Thirty-nine patients (11%) had stage IV disease and 20 (5%) had locally recurrent cancer. There was a documented change in plan as a result of the CRC-MDC discussion in 97 of 371 (26%) cases surveyed. Changes in management included a change in therapy or change in therapy sequence in 76 cases, and recommendation of additional evaluation in 36 cases. Rates of management change were similar regardless of surgeon experience. Changes occurred in 23%, 28%, and 26% of cases presented by surgeons with <10, 10 to 20, and >20 years of experience, respectively (chi-square p= 0.63). The CRC-MDC changes clinical management for a significant portion of rectal cancer patients at a tertiary center, independent of the presenting surgeon's years of clinical experience. Our results support the CRC-MDC standard for the National Accreditation Program for Rectal Cancer.

Systemic Chemotherapy as Salvage Treatment for Locally Advanced Rectal Cancer Patients Who Fail to Respond to Standard Neoadjuvant Chemoradiotherapy

The potential of chemotherapy as salvage treatment after failure of neoadjuvant chemoradiotherapy for locally advanced rectal cancer (LARC) has never been explored. We conducted a single-center, retrospective analysis to address this question. Patients with newly diagnosed LARC who were inoperable or candidates for extensive (i.e., beyond total mesorectal excision [TME]) surgery after long-course chemoradiotherapy and who received salvage chemotherapy were included. The primary objective was to estimate the proportion of patients who became suitable for TME after chemotherapy. Forty-five patients were eligible (39 candidates for extensive surgery and 6 unresectable). Previous radiotherapy was given concurrently with chemotherapy in 43 cases (median dose: 54.0 Gy). Oxaliplatin- and irinotecan-based salvage chemotherapy was administered in 40 (88.9%) and 5 (11.1%) cases, respectively. Eight patients (17.8%) became suitable for TME after chemotherapy, 10 (22.2%) ultimately underwent TME with clear margins, and 2 (4.4%) were managed with a watch and wait approach. Additionally, 13 patients had extensive surgery with curative intent. Three-year progression-free survival and 5-year overall survival in the entire population were 30.0% (95% confidence interval [CI]: 15.0-46.0) and 44.0% (95% CI: 26.0-61.0), respectively. For the curatively resected and "watch and wait" patients, these figures were 52.0% (95% CI: 27.0-73.0) and 67.0% (95% CI: 40.0-84.0), respectively. Systemic chemotherapy may be an effective salvage strategy for LARC patients who fail to respond to chemoradiotherapy and are inoperable or candidates for beyond TME surgery. According to our study, one out of five patients may become resectable or be spared from an extensive surgery after systemic chemotherapy. High-quality evidence to inform the optimal management of rectal cancer patients who are inoperable or candidates for beyond total mesorectal excision surgery following standard chemoradiotherapy is lacking. We show for the first time that systemic chemotherapy may be beneficial and result in one out of five poor prognosis patients becoming resectable or being spared from an extensive surgical approach. Although mores studies are needed to confirm these data, administering salvage systemic chemotherapy in this setting may have the potential to minimize morbidity associated with extensive surgical procedures and improve long-term oncological outcome.

A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design

BackgroundTotal mesorectal excision is the standard surgical treatment for mid- and low-rectal cancer. Laparoscopy represents a clear leap forward in the management of rectal cancer patients, offering significant improvements in post-operative measures such as pain, first bowel movement, and hospital length of stay. However, there are still some limits to its applications, especially in difficult cases. Such cases may entail either conversion to an open procedure or positive resection margins. Transanal endoscopic proctectomy (ETAP) was recently described and could address the difficulties of approaching the lower third of the rectum. Early series and case-control studies have shown favourable short-term results, such as a low conversion rate, reduced hospital length of stay and oncological outcomes comparable to laparoscopic surgery. The aim of the proposed study is to compare the rate of positive resection margins (R1 resection) with ETAP versus laparoscopic proctectomy (LAP), with patients randomly assigned to each arm.Methods/designThe proposed study is a multicentre randomised trial using two parallel groups to compare ETAP and LAP. Patients with T3 lower-third rectal adenocarcinomas for whom conservative surgery with manual coloanal anastomosis is planned will be recruited. Randomisation will be performed immediately prior to surgery after ensuring that the patient meets the inclusion criteria and completing the baseline functional and quality of life tests. The study is designed as a non-inferiority trial with a main criterion of R0/R1 resection. Secondary endpoints will include the conversion rate, the minimal invasiveness of the abdominal approach, postoperative morbidity, the length of hospital stay, mesorectal macroscopic assessment, functional urologic and sexual results, faecal continence, global quality of life, stoma-free survival, and disease-free survival at 3 years. The inclusion period will be 3 years, and every patient will be followed for 3 years. The number of patients needed is 226.DiscussionThere is a strong need for optimal evaluation of the ETAP because of substancial changes in the operative technique. Assessment of oncological safety and septic risk, as well as digestive and urological functional results, is particularily mandatory. Moreover, benefits of the ETAP technique could be demonstrated in post-operative outcome.Trial registrationClinicalTrial.gov: NCT02584985.Date and version identifier: Version n°2 – 2015 July 6.

Application effect of "disease-characteristics nursing quality improvement" program in the management of rectal cancer patients

Objective To explore the clinical effect of disease-characteristics nursing quality improvement program (DNQIP) in improving the nursing quality of rectal cancer patients. Methods On basis of patient-centered and evidence-based practice, Department of General Surgery of Peking University First Hospital searched for the optimal nursing practice, created the characteristic management of rectal cancer and implemented the DNQIP program. We explored and compared the differences of patients in patient satisfaction, nurses' satisfaction, disease management index before (2012) and after (2015) the implementation of DNQIP. Results Compared with the indicatiors before the implementation, DNQIP effectively improved patient satisfaction (χ2=18.990, P<0.001) , nurses' satisfaction (χ2=9.463, P=0.002) , increased the number of stoma positioning (χ2=17.053, P<0.001) , decreased the incidence rate of the stoma complications (χ2=5.291, P=0.021) , increased outpatient follow-up number (χ2=10.459, P=0.001) and effectively shorten the average length of stay (ALOS) (t=128.34, P<0.001) . Conclusions DNQIP is an effective method to improve the nursing quality of patients with rectal cancer. Key words: Rectal tumor; Specialist nursing; Disease-characteristics nursing quality improvement program

Essential Items for Structured Reporting of Rectal Cancer MRI: 2016 Consensus Recommendation from the Korean Society of Abdominal Radiology.

High-resolution rectal MRI plays a crucial role in evaluating rectal cancer by providing multiple prognostic findings and imaging features that guide proper patient management. Quality reporting is critical for accurate effective communication of the information among multiple disciplines, for which a systematic structured approach is beneficial. Existing guides on reporting of rectal MRI are divergent on some issues, largely reflecting the differences in overall management of rectal cancer patients between the United States and Europe. The Korean Society of Abdominal Radiology (KSAR) study group for rectal cancer has developed an expert consensus recommendation regarding essential items for structured reporting of rectal cancer MRI using a modified Delphi method. This recommendation aims at presenting an up-to-date, evidence-based, practical, structured reporting template that can be readily adopted in daily clinical practice. In addition, a thorough explanation of the clinical and scientific rationale underlying the reporting items and their formats is provided. This KSAR recommendation may serve as a useful tool to help achieve more standardized optimal care for rectal cancer patients using rectal MRI.

Magnetic resonance imaging for the clinical management of rectal cancer patients: recommendations from the 2012 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting

To develop guidelines describing a standardised approach regarding the acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for clinical staging and restaging of rectal cancer. A consensus meeting of 14 abdominal imaging experts from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) was conducted following the RAND-UCLA Appropriateness Method. Two independent (non-voting) chairs facilitated the meeting. Two hundred and thirty-six items were scored by participants for appropriateness and classified subsequently as appropriate or inappropriate (defined by ≥ 80% consensus) or uncertain (defined by <80% consensus). Items not reaching 80% consensus were noted. Consensus was reached for 88% of items: recommendations regarding hardware, patient preparation, imaging sequences, angulation, criteria for MRI assessment and MRI reporting were constructed from these. These expert consensus recommendations can be used as clinical guidelines for primary staging and restaging of rectal cancer using MRI. • These guidelines recommend standardised imaging for staging and restaging of rectal cancer. • The guidelines were constructed through consensus amongst 14 abdominal imaging experts. • Consensus was reached by in 88% of 236 items discussed.

Role of intra- and peritumoral budding in the interdisciplinary management of rectal cancer patients.

The presence of tumor budding (TuB) at the invasive front of rectal cancers is a valuable indicator of tumor aggressiveness. Tumor buds, typically identified as single cells or small tumor cell clusters detached from the main tumor body, are characterized by loss of cell adhesion, increased migratory, and invasion potential and have been referred to as malignant stem cells. The adverse clinical outcome of patients with a high-grade TuB phenotype has consistently been demonstrated. TuB is a category IIB prognostic factor; it has yet to be investigated in the prospective setting. The value of TuB in oncological and pathological practice goes beyond its use as a simple histomorphological marker of tumor aggressiveness. In this paper, we outline three situations in which the assessment of TuB may have direct implications on treatment within the multidisciplinary management of patients with rectal cancer: (a) patients with TNM stage II (i.e., T3/T4, N0) disease potentially benefitting from adjuvant therapy, (b) patients with early submucosally invasive (T1, sm1-sm3) carcinomas at a high risk of nodal positivity and (c) the role of intratumoral budding assessed in preoperative biopsies as a marker for lymph node and distant metastasis thus potentially aiding the identification of patients suitable for neoadjuvant therapy.

Role of tumor size in the pre-operative management of rectal cancer patients

BackgroundClinical management of rectal cancer patients relies on pre-operative staging. Studies however continue to report moderate degrees of over/understaging as well as inter-observer variability. The aim of this study was to determine the sensitivity, specificity and accuracy of tumor size for predicting T and N stages in pre-operatively untreated rectal cancers.MethodsWe examined a test cohort of 418 well-documented patients with pre-operatively untreated rectal cancer admitted to the University Hospital of Basel between 1987 and 1996. Classification and regression tree (CART) and logistic regression analysis were carried out to determine the ability of tumor size to discriminate between early (pT1-2) and late (pT3-4) T stages and between node-negative (pN0) and node-positive (pN1-2) patients. Results were validated by an external patient cohort (n = 28).ResultsA tumor diameter threshold of 34 mm was identified from the test cohort resulting in a sensitivity and specificity for late T stage of 76.3%, and 67.4%, respectively and an odds ratio (OR) of 6.67 (95%CI:3.4-12.9). At a threshold value of 29 mm, sensitivity and specificity for node-positive disease were 94% and 15.5%, respectively with an OR of 3.02 (95%CI:1.5-6.1). Applying these threshold values to the validation cohort, sensitivity and specificity for T stage were 73.7% and 77.8% and for N stage 50% and 75%, respectively.ConclusionsTumor size at a threshold value of 34 mm is a reproducible predictive factor for late T stage in rectal cancers. Tumor size may help to complement clinical staging and further optimize the pre-operative management of patients with rectal cancer.

Ultrasound Staging of Rectal Cancer

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.

Surgical treatment for rectal cancer: An international perspective on what the medical gastroenterologist needs to know

Rectal cancer accounts for one third of all colorectal cancers. The age adjusted death rates from colorectal cancer have declined over recent decades due to a combination of colorectal cancer screening, improved diagnostic tests, improved standardized surgical technique, improved medical support, neoadjuvant chemotherapies and radiation treatment or combinations of these. Because of complex treatment algorithms, use of multidisciplinary teams in the management of rectal cancer patients has also been popularized. Medical gastroenterologists performing colonoscopies are frequently the first health care provider to raise the suspicion of a rectal cancer. Although the diagnosis depends on histological confirmation, the endoscopic presentation is almost diagnostic in many cases. In order to meet the patient's immediate needs for information, it is important that the endoscopist has knowledge about the investigations and treatment options that will be required for their patient. The aim of this paper is to describe the modern preoperative investigations and operative procedures commonly offered to rectal cancer patients taking into account perspectives of three colorectal surgeons, practicing in the USA, Europe and Asia.

USPIO – enhanced rectal cancer specimen MRI: how well does it correlate with node identification at histopathology?

Introduction: Detection of lymph node (LN) metastasis is important for the optimal management of rectal cancer patients. Ultrasmall‐particle superparamagnetic iron oxide (USPIO) contrast enhanced magnetic resonance imaging (MRI) has emerged as an effective method of assessing nodal involvement in various malignancies. We have investigated the correlation between nodes seen on specimen MRI and those found at histopathology and the optimum time interval between contrast injection and surgery in USPIO mesorectal lymphography.Method: Thirteen rectal cancer patients underwent MRI before and 24 h after intravenous infusion of USPIO contrast (Sinerem®, Advanced Magnetics Inc, Cambridge, MA, USA). Total Mesorectal Excision (TME) surgery was followed by fixed specimen MRI. Lymph nodes seen on specimen MRI and those found at pathology were compared for studies performed &lt;5 days and ≥5 days prior to surgery.Results: Histopathological LNs found correlated well with those seen on specimen MRI (all patients, r = 0.73; P = 0.005, figure). Correlation was better for the &lt;5 day group (r = 0.84; P = 0.01) than for the ≥5 day group (r = 0.54; P = 0.35). Discussion: USPIO specimen MRI is useful in mesorectal LN assessment. We demonstrate good correlation between specimen MRI and histopathology and show that fewer errors occur in assessment when the time interval between contrast injection and surgery is &lt;5 days.

MRI in rectal cancer: the T stage and circumferential resection margin.

Different stages of rectal cancer show differing degrees of risk for local recurrence. Paramount for the selection and differentiated treatment of the different risk groups is a reliable preoperative test that can distinguish between these subgroups. There is recent evidence suggesting that MRI can serve for this purpose, because it accurately predicts the circumferential resection margin. In this article the role of MRI in the preoperative management of rectal cancer patients will be discussed.

Pelvic radiological imaging: a surgeon's perspective

Radiological imaging of the pelvis adds an important dimension to our understanding of rectal and perianal disease. By integrating relevant information obtained from these investigations into planning and conduct of surgical procedures, outcomes for patients may be optimised. This review focuses on three areas from a clinical viewpoint. (1) With the increased use of neoadjuvant treatments pretherapeutic staging strategies become central to the management of rectal cancer patients. At present, transrectal ultrasound (TRUS), computerised tomography and magnetic resonance imaging (MRI) serve in combination to provide the essential informations. (2) The advent of endoanal ultrasound and MRI in the diagnostic workup of patients with faecal incontinence has caused a paradigm shift both conceptionally and in the way treatments are tailored to individual patients. (3) Concerning primary perianal fistulas there is little place for endoanal ultrasound or MRI. However, when a recurrent or Crohn's fistula is present, a combination of surgical exploration with either endoanal ultrasound or MRI depending on local expertise and availability may be the optimal approach to maximise benefit for these patients.

Adjuvant treatment of patients with rectal cancer

Adjuvant postoperative radiotherapy combined with chemotherapy is considered a standard management of rectal cancer patients with increased risk of local recurrence. In this study we evaluated the results of adjuvant chemo- and radiotherapy after radical surgery in 64 patients with rectal carcinoma with special reference to tolerance of treatment. All patients underwent radical surgery: anterior abdominal resection in 26, abdominoperineal resection in 19 and Hartman resection in one. Thirty three patients were postoperatively staged as Dukes B2 and 31 patients – as Dukes C. All patients received postoperative chemo-radiotherapy. Treatment included megavoltage irradiation with two parallel opposed fields to small pelvis at a dose of 45 Gy in 23–25 fractions and concomitant chemotherapy with 5-Fluorouracil during first three and last three days of irradiation. Main early complications from chemoradiation included diarrhea (58%), nausea and vomiting (15%), dysuria (6%), leukopenia (31%) and anaemia (4%). In total, acute side effects occured in 42 patients (66%) and in 16 of them (25%) were of grade 3 or 4. Three patients did not complete the treatment due to exacerbation of side effects and/or serious deterioration of performance status. Late complications, mainly from bowels and urinary bladder, occured in 19 patients (30%) and six of then (9%) were severe. Nineteen of the 64 evaluated patients have deceased ill now. Median survival was 29 months (4 to 50 months). Local recurrence was seen in 14 patients (22%) and distant metastases – in 18 (28%). Results of our study show that postoperative radiochemotherapy in rectal cancer patients is accompanied by a large number of acute and late complications. Literature data demonstrate that better tolerance of treatment may be achieved with the use of special surgical techniques preventing the replacement of small intestines to the pelvis after rectal amputation. Further improvement may be achieved with the use of multiple radiation fields, computerized treatment planning and customized blocking. Another option is an application of preoperative radiotherapy – the approach becoming recently more commonly used.