Mesorectal Nodes Research Articles

PTH-274 Is local excision alone an appropriate option for good clinical responders after chemoradiation in rectal cancers?

Introduction Local excision (LE) is emerging as a treatment option for rectal cancers responding well to chemoradiation. However, LE does not address the mesorectal nodal burden. We aimed to identify factors influencing nodal positivity and subsequently defined a good risk group by including only patients at low risk. Method Single centre, retrospective analysis of a prospectively maintained database of radically resected rectal cancer patients post neoadjuvant chemoradiation. Results 524 patients with predominantly low rectal tumours were included. Nodal positivity among ypT0, T1 and T2 groups was 14.7%, 28% and 30%,respectively. The following good risk features were identified: age > 40 years,histologic subtype (classical and mucinous variants) and pathological complete response. 69 patients satisfying all 3 criteria were analysed and the nodal positivity was 10.1% which implies that if we had selected these patients for LE, 1 out of 10 patients would have had unaddressed mesorectal nodes Conclusion LE cannot be used as a guide to observe patients with complete pathological response as the residual nodal burden will lead to more local recurrences thus impacting survival in an otherwise good prognostic subset. Disclosure of interest None Declared.

Primary Malignant Melanoma of the Rectum: Long-Term Disease-Free Survival Following Abdomino-Perineal Resection

Objective: Primary Malignant Melanoma (PMM) arising from the digestive, respiratory or genitourinary tract is extremely rare. Rectal PMM accounts for less than 1% of all melanomas; it is often advanced at initial presentation with a poor prognosis with a 5-year survival below 20%. Treatment of this particular disease is still debated with weak evidence that aggressive surgery may lead to a better outcome. The objective of the present paper is to descibe a case of PMM and review the published literature on the treatment of such extremely rare condition. Methods: A 78 years old man presenting mild anal bleeding underwent a colonoscopy which showed a centimetric mass in the posterior wall of the rectum, less than 1 cm above the pectinea line. Biopsy revealed amelanotic malignant melanoma infiltrating the submucosa. Preoperative assessment revealed no distant metastases and no nodal involvement. Abdominoperineal resection (APR) with total mesorectal excision and iliac nodes sampling was performed. Results: the patient is alive and disease-free after 48 months from diagnosis. According to a literature review, APR with or without intra abdominal pelvic lymph node dissection represents a more radical approach in patients seeking curative options. However, some series suggest that wide local excision (WLE) may have similar survival outcomes but seems to be burdened with a higher rate of local recurrences. Conclusions: Our experience confirms that treatment recommendations are not standardized and tend to be individualized. An aggressive surgical approach may be justified in patient with a long life expectancy accepting a demolitive surgery and a definitive colonostomy.

Size and distribution of lymph nodes in rectal cancer resection specimens.

The detection of lymph node involvement is fundamental to the staging of rectal cancer, and aids in prognostication and identification of patients who will benefit from adjuvant therapy. The anatomical variation in distribution and size of mesorectal lymph nodes has received scant attention. This study aimed to determine the size and distribution of lymph nodes in rectal cancer resection specimens. This was a prospective, observational study of rectal cancer resection specimens analyzed by a single histopathologist. This study was conducted from January 2007 to July 2013 at the authors' institution. Two hundred forty-four consecutive patients underwent resection for rectal cancer. The size and distribution of lymph nodes in the resection specimens and the anatomical position of mesorectal lymph nodes in relation to the peritoneal reflection, tumor, and anal verge were recorded. A total of 10,473 lymph nodes were retrieved in 244 patients (75 women; median age, 68 years (interquartile range, 59-75 years)). One hundred seventy-three anterior resection and 71 abdominoperineal resection specimens were analyzed. Median lymph node yield was 41 lymph nodes (interquartile range, 31-52); 344 of 10,473 (3.2%) lymph nodes were positive. Lymph nodes were distributed in the mesorectum, sigmoid mesentery, and vascular pedicle in 40%, 32%, and 28% of the patients. Sixty-eight percent of mesorectal lymph nodes were above the peritoneal reflection. Mesorectal lymph node distribution in relation to the tumor was 53% above, 36% adjacent to, and only 11% below the tumor. Ninety-five of 334 (28%) positive nodes were ≤3 mm in diameter. Resection specimens analyzed by other pathologists (<5%) have not been included, and fat clearance techniques were not used to retrieve lymph nodes. To ensure accurate nodal staging of rectal cancer, both resection and subsequent pathological evaluation should focus on the mesorectum in close proximity to the tumor and along the superior rectal artery. Small lymph nodes (<3 mm in size) should not be overlooked, and lymph node metastasis to the sigmoid mesentery is rare (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A177).

Preoperative chemoradiotherapy for clinically diagnosed T3N0 rectal cancer.

This retrospective study compared the recurrence-free survival (RFS) and local recurrence rates of patients who received preoperative chemoradiotherapy (PCRT) for cT3N0 vs. those who did not. We analyzed the records of 593 patients with transrectal ultrasound (TUS) or magnetic resonance image (MRI)-staged cT3N0 mid and low locally advanced rectal cancer, including 255 who received PCRT and 338 who did not. The RFS and cumulative local recurrence rates were compared in the two groups. We also investigated the rates of pathologic complete response (pCR) and mesorectal lymph node (LN) involvement in the PCRT group. The overall pCR rate was 13.3%. Of the 338 non-PCRT patients, 125 (37.0%) had pathologically positive mesorectal LNs. Sphincter-preserving surgery was performed in 431 (72.7%) of the 593 patients, with similar rates in the two groups. However, the sphincter preservation rate in patients with low rectal cancer was higher among those who received PCRT than among those who did not (64.8 vs. 47%, P=0.002). The 5-year RFS (76.4 vs. 75.5%, P=0.92) and local recurrence (3.9 vs. 3.0%, P=0.97) rates were similar in the PCRT and non-PCRT groups. Although PCRT did not improve the RFS or local recurrence rates, it increased the chance of sphincter preservation in patients with low rectal cancer. The advantages of PCRT for patients with cT3N0 should be re-evaluated considering the limitation of pretreatment staging, oncologic benefits, and improved sphincter preservation.

Metastasization of mesorectal lymph nodes by a prostatic adenocarcinoma

We present two patients with metastasis of a prostate carcinoma in the mesorectal lymphatic nodes. After these findings, we retrieve and review the hematoxylin and eosin (HE) slides of 22 other surgical specimens from patients presenting both synchronic tumours from the records of the Registry of Tumours of our hospital from 1999 to 2005. Histological findings in the lymph nodes were consistent with prostate carcinoma and confirmed by immunohistochemistry expressing positivitiy for PSA and negativity for CEA and CK20. No metastasis of the prostate cancer to lymphatic mesorectal nodes was histologically found in any of the 22 cases reviewed with synchronous rectal and prostate carcinoma. Our findings also support the existence of connections between the lymphatic drainage of the mesorectum and the hypogastric lymphatic drainage.

Intersphincteric resection and hand-sewn coloanal anastomosis for low rectal cancer: Short-term outcomes in the Indian setting.

The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario. All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay. Thirty-three patients with low rectal cancer and a median age of 38years underwent ISR during the defined study period. Twenty-three patients (70%) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300mL and 7days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes. Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

Pathologic evaluation of the response of mesorectal positive nodes to preoperative chemoradiotherapy in patients with rectal cancer

The response of positive mesorectal lymph nodes to chemoradiotherapy remains largely unstudied in patients with rectal cancer. The aim of this study was to investigate the requirements of the total regression of positive nodes treated with chemoradiotherapy. The response of the primary tumor was evaluated according to the tumor regression grade (TRG 0-4) in resected specimens, and positive lymph nodes were assessed according to the lymph node regression grade (LRG 1-3), with TRG 4 and LRG 3 indicating total regression. We investigated the relationships among TRG, LRG, and the sizes of positive lymph nodes. Among 178 patients, 68 (38.2%) had 200 positive lymph nodes. We first investigated the relationship of positive nodes to TRG and LRG and found that the response of the primary tumor to chemoradiotherapy correlated with the response of positive nodes. Next, we investigated the correlation between LRG and the size of positive nodes. At TRG 1 and 2, LRG score was not correlated with the positive node size. In contrast, at TRG 3, LRG score was correlated with the size of positive nodes. Next, our assessment of the relationship between the sizes of positive nodes and complete degeneration to LRG 3 showed that the most accurate cut-off score on receiver-operator-characteristics curve analysis was 6 mm in maximum diameter for TRG 3. The requirements of the total regression of positive nodes are 1) degeneration of the primary tumor to TRG 3 and 2) a positive node diameter of <6 mm.

Prognostic factors for curative pelvic exenterations in patients with recurrent uterine cervical or vaginal cancer.

The aim of this study was to assess the prognostic factors after curative pelvic exenterations performed for recurrent uterine cervical or vaginal cancers in the era of concomitant chemoradiotherapy. We retrospectively enrolled 16 patients with recurrent uterine cervical or vaginal cancer and tumor-free resection margins on pelvic exenteration pathological analysis between October 1997 and April 2014. Pelvic exenterations were performed for 13 recurrent cervical cancers and 3 recurrent vaginal cancers. All of the patients had received pelvic irradiation (external radiotherapy for 14 patients and brachytherapy for 2 patients). The median age at the recurrence was 59.5 years (49-77 years), and the median tumor size was 4.35 cm (2-9 cm). There were no intraoperative or postoperative deaths. The 5-year disease-free survival and overall survival were 30% and 34.1%, respectively. The following 3 factors affected the disease-free survival: tumor size greater than 5 cm (P = 0.05), mesorectal lymph node involvement (P = 0.02), and vascular emboli (P = 0.0093). The presence of vascular emboli is a new prognostic factor in cases of recurrent cervical or vaginal cancer. Assessing the presence of vascular emboli on pretherapeutic biopsies could facilitate the selection of patients eligible for curative pelvic exenterations.

Prediction of metastasis to mesorectal, internal iliac and obturator lymph nodes according to size criteria in patients with locally advanced lower rectal cancer

This study was performed to clarify whether size criteria could be applied to the prediction of metastasis to the mesorectal, internal iliac and obturator lymph nodes in patients with lower rectal cancer. A total of 915 lymph nodes (416 mesorectal, 199 internal iliac and 300 obturator) from 53 patients with lower rectal cancer who underwent a curative resection were examined; 83 lymph nodes were positive. The sizes of the lymph nodes immediately after removal and those of paraffin-embedded sections were compared for 175 lymph nodes. Then, size criteria for discriminating the status of metastasis were evaluated in 915 paraffin-embedded lymph nodes. Regardless of the metastatic status and the site of the lymph nodes, a positive relationship was observed between the sizes of the lymph nodes immediately after removal and those of paraffin-embedded sections (P < 0.01). The area under the curve generated by a receiver-operating characteristics curve showed no significant differences between the short-axis diameter and the long-axis diameter, regardless of the lymph node location. Specifically, the optimal cutoff value of the short-axis diameter for discriminating the status of metastasis in mesorectal, internal iliac and obturator lymph nodes extrapolated to the living body was set at 6.2, 5.0 and 4.8 mm, with accuracies of 72.4, 63.8 and 59.3% and with positive predictive values of 29.9, 16.3 and 7.1%, respectively. Size criteria were applicable for discriminating the metastatic status of lymph nodes from three different locations, although the positive predictive values of the size criteria for the internal iliac and obturator lymph nodes were lower than that for the mesorectal lymph nodes.

Diagnostic Performance of Multidetector Row Computed Tomography for Assessment of Lymph Node Metastasis in Patients with Distal Rectal Cancer

The accurate preoperative diagnosis of depth of tumor invasion and nodal status in distal rectal cancer is important because neoadjuvant chemotherapy or lateral pelvic lymph node dissection is indicated for patients with T3-T4 tumor or nodal involvement. This study aimed to determine the optimal cutoff value for predicting lymph node metastasis in patients with distal rectal cancer using multidetector row computed tomography (MDCT). The study investigated 77 patients who had undergone surgery for distal rectal cancer at a single institution between 2008 and 2011. Diagnostic performance for depth of tumor invasion and mesorectal and lateral pelvic lymph node metastases was evaluated. The optimal cutoff value was determined by receiver operating characteristic curve analysis. For predicting mesorectal and lateral pelvic lymph node metastasis, MDCT had a sensitivity of 0.36 and 0.89 and a specificity of 0.78 and 0.97, respectively. The optimal cutoff values of major and minor axes lengths for predicting mesorectal lymph node metastasis were 6.5 mm and 5.7 mm, respectively. The areas under the curve (AUCs) were 0.82 and 0.88, respectively. For predicting lateral lymph node metastasis, the optimal cutoff values were 9 mm for the major axis and 6 mm for the minor axis. Both AUCs were 1. Using MDCT, the optimal cutoff value of minor axis length for predicting mesorectal and lateral pelvic lymph node metastases in patients with distal rectal cancer was 6 mm. The accuracy of MDCT was satisfactory for predicting lateral pelvic lymph node metastasis.

Multiple Liver Lesions in a Patient With Positive Hepatitis C Serology and Elevated AFP: Is It HCC?

Question: A 41-year-old Tongan man presented with acute-onset right upper quadrant pain, worse with inspiration, and radiating to the right shoulder tip. He reported intermittent diarrhea over the past few months and small amounts of bright red rectal bleeding over the preceding 3 years. He had no fevers and no loss of weight. He had no significant past medical history except for pneumonia several years previously and was not taking any regular medications. He was a former smoker and drank alcohol once per month but consumed large amounts of kava (Piper methysticum). Clinical examination revealed right upper quadrant tenderness without guarding and normal chest auscultation. Laboratory analysis revealed deranged liver tests with alanine aminotransferase of 45 IU/L (normal, <40), alkaline phosphatase of 157 IU/L (normal, <120), γ-glutamyltransferase of 559 IU/L (normal, <71), and positive hepatitis C antibody enzyme immunoassay. Computed tomographic pulmonary angiography showed no evidence of pulmonary embolism, but incidentally noted multiple hypodense liver lesions, the largest lying posteriorly in the subdiaphragmatic region of liver segment VII measuring 6 cm in maximal diameter on axial sequences (Figure A). Tumor marker analysis found a significantly elevated alpha-fetoprotein (AFP) of 135,070 IU/mL (normal, <7). Subsequent multiphase computed tomography of the abdomen and pelvis confirmed multiple hypodense, nonarterially enhancing lesions within the liver. The liver did not seem to be cirrhotic and there were no signs of portal hypertension. In addition, several enlarged left mesorectal lymph nodes were noted with adjacent irregular rectal wall thickening (Figure B). What is the most likely diagnosis? What further investigations are required to confirm the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Liver lesions in patients with positive hepatitis C antibody tests should raise suspicion for hepatocellular carcinoma (HCC). However, the hepatic lesions did not fulfil imaging criteria for this diagnosis. In addition, the patient had only been tested for hepatitis C virus (HCV) antibodies and confirmation of HCV infection with hepatitis C polymerase chain reaction (PCR) testing was still awaited. The reported sensitivity and specificity of AFP for detecting HCC are 60% and 90%, respectively, at an AFP of 20 IU/mL in patients with cirrhosis.1Trevisani F. D'Intino P.E. Morselli-Labate A.M. et al.Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HBsAg and anti-HCV status.J Hepatol. 2001; 34: 570-575Abstract Full Text Full Text PDF PubMed Scopus (569) Google Scholar AFP may also be elevated in extrahepatic malignancies, including gonadal germ cell tumors and rarely in tumors of the pancreas, gallbladder, stomach, and colon. There are few case reports of AFP-producing colon carcinomas with most occurring in adult males, located in the rectum, with AFP levels of several thousand IU/mL.2Yachida S. Fukushima N. Nakanishi Y. et al.Alpha-fetoprotein-producing carcinoma of the colon: report of a case and review of the literature.Dis Colon Rectum. 2003; 46: 826-831Crossref PubMed Scopus (29) Google Scholar In view of the computed tomography findings of rectal thickening, colonoscopy was performed and revealed a polypoid, ulcerated rectal mass (Figure C). Histology confirmed poorly differentiated adenocarcinoma with positive immunostaining for AFP (Figure D). Ultrasound-guided biopsy of one of the echogenic liver lesions showed similar tumor and again was strongly positive for AFP (Figure E). The normal liver biopsy showed normal liver architecture with no evidence of fibrosis (Figure F). Confirmatory HCV recombinant immunoblot assay (RIBA) was negative and serum HCV RNA was not detected. The patient was referred for chemotherapy. This case highlights the need to confirm positive HCV enzyme immunoassays with RIBA or HCV-RNA PCR because EIAs can yield low positive predictive values among populations with a low prevalence of HCV infection.3Kamili S. Drobeniuc J. Araujo A.C. et al.Laboratory diagnostics for hepatitis C virus infection.Clin Infect Dis. 2012; 55: S43-S48Crossref PubMed Scopus (131) Google Scholar Furthermore, AFP can arise from malignancies other than HCC and histologic confirmation is recommended in patients with liver lesions that are atypical for HCC on imaging.

Neoadjuvant therapy followed by local excision and two-stage total mesorectal excision: a new strategy for sphincter preservation in locally advanced ultra-low rectal cancer.

Background: With the increased usage of neoadjuvant chemoradiotherapy, improved surgical technique and stapling devices, sphincter-preserving resection has become more frequent for patients with rectal cancer. However, as for locally advanced ultra-low rectal cancer, sphincter-preservation is still facing an enormous challenge.Objective: To introduce an NLT strategy of sphincter-preservation—neoadjuvant therapy (NT) followed by local excision (LE) and two-stage total mesorectal excision (TME)—into the treatment of locally advanced ultra-low rectal cancer (lesions with anal sphincter invasion).Methods: From October 2010 to October 2011, nine patients with locally advanced rectal cancer located less than 3 cm from the anal verge were treated by the NLT strategy. All patients had shown good clinical response to NT. The LE procedure was carried transanally 6–8 weeks after completion of the NT. TME was performed to dissect mesorectal lymph nodes 4–6 weeks after LE.Results: Of the nine patients, the lesion was assessed as T2 in two, T3 in five, and T4 in two before NT, and lymph node metastasis was detected in five patients. The median distance from the tumor to the anal verge was 2.5 cm (range: 1–3 cm). The median follow-up was 27 months (range: 24–34 months). No distant metastasis was detected. Only one patient (11.1%) developed local recurrence at 12 months post-operatively and then underwent abdomino-perineal resection. The remaining eight patients had preserved long-term continence and the median Wexner score at two years post-operation was 4 (range: 2–6).Conclusion: The new NLT strategy can achieve sphincter-preservation in some patients with ultra-low rectal cancer, with favorable oncological outcome and preservation of normal anal sphincter function.

Pelvic side wall nodes in locally advanced rectal cancer as a prognostic indicator.

613 Background: Neoadjuvant long course chemoradiotherapy is a well recognised treatment in locally advanced rectal cancer. Patients with pelvic side wall nodes are often considered for neoadjuvant treatment. We investigated whether pelvic side wall nodes identified on pre-treatment imaging is a poor prognostic factor and whether there are different patterns of recurrence compared to patients without pelvic side wall node involvement. Methods: All patients treated with long course chemoradiotherapy between January 2008 and December 2009 were identified. Patients were excluded if treatment indication was for inoperable disease, postoperative, recurrence, or palliative intent. 231 patients were identified and a retrospective analysis performed investigating patterns of recurrence and survival for patients with pelvic side wall nodes identified on pre-treatment imaging. Results: Kaplan Meier curves are presented showing patients with pelvic side wall nodes identified on pre-treatment imaging appear to have poorer outcomes and overall survival compared with those with only mesorectal nodes or no nodes. Patterns of recurrence are presented, showing patients with pelvic side wall nodes identified on pre-treatment imaging have a non significant trend to increased rates of disease recurrence (local and distal recurrence combined, 45.7% versus 27.9% for pelvic side wall nodes versus no pelvic side wall nodes). Patients with pelvic side wall nodes identified on pre-treatment imaging appear to be more likely to develop distant metastases compared to those patients who have mesorectal nodes or no nodal involvement (37% versus 23%). Conclusions: Our study highlights that patients with pelvic side wall nodes identified on pre-treatment imaging appear to have a trend to poorer overall survival, are more likely to recur and develop distant metastases. These results were not statistically significant, due to the small number of patients, and the data is consequently limited. We intend to further investigate current management strategies for this subgroup of patients, with assessment of radiotherapy treatment plans, current use of integral boosts, and surgical procedures for this subgroup of patients.

Residual rectal cancer after preoperative radiochemotherapy (ypT1-2): An indication for local excision instead of radical surgery?

546 Background: Preoperative radiochemotherapy (RCT) followed by total mesorectal excision (TME) has improved local tumor control and led to a significant tumor downstaging. For patients with pathologic complete response (ypT0) as well as residual tumor restricted only to the bowel wall (ypT1-2) local excision has increasingly been discussed to avoid significant morbidity and functional deficits associated with TME. Therefore we investigated the incidence, distribution and tumor-related localization of mesorectal lymph node (LN) metastases in TME specimens with ypT0, ypT1-2 and ypT3-4 rectal cancers, respectively. Methods: TME specimens from 81 patients with locally advanced rectal cancer treated with neoadjuvant RCT within the phase III German Rectal Cancer Trial CAO/ARO/AIO-04 were evaluated. The entire mesorectal compartment was screened microscopically after complete paraffin embedding. The number and localization of all detectable LN metastases was specified in relation to the primary tumor. Results: Whereas 50 patients (62%) had ypT3-4 carcinomas after neoadjuvant RCT 20 patients (25%) presented with residual tumor within the bowel wall (ypT1-2). 11 patients (14%) had pathologic complete response (ypT0). 28 ± 13.7 LN were detected per specimen. 25 patients (31%) had residual LN metastases after RCT. Although the incidence was higher in the ypT3-4 group (40% ypN+) still 25% of patients in the ypT1-2 group had a mean number of 2.2 residual LN metastases. 55% of these metastases were located afar from the primary lesion in the proximal mesorectum. No patient with ypT0 status had residual LN metastases. Conclusions: Even in patients with good response and tumors restricted only to the bowel wall (ypT1-2) after RCT there is a considerable risk for residual LN metastases. The majority of metastases were located clearly outside the tumor region. Local excision of residual rectal cancer would be accompanied by a higher rate of local failure and radical surgery with TME should remain the standard treatment in those patients.

Magnetic resonance imaging in rectal cancer: A surgeon’s perspective

Magnetic resonance imaging (MRI) in rectal cancer was first investigated in 1999 and has become almost mandatory in planning rectal cancer treatment. MRI has a high accuracy in predicting circumferential resection margin involvement and is used to plan neoadjuvant therapy. The accuracy of MRI in assessing mesorectal lymph nodes remains moderate, as there are no reliable criteria to assess nodal involvement. MRI seems to be good in assessing peritoneal involvement in upper rectal cancer; this however has been assessed in only a few studies and needs further research. For low rectal cancers, mesorectum is thin at the level of levator ani especially in relation to prostate; so predicting circumferential resection margin involvement is not easy. However high spatial resolution coronal imaging shows levator muscles, sphincter complex and intersphincteric plane accurately. This is used to stage low rectal tumors and plan plane of surgery (standard surgery, intersphincteric resection, Extralevator abdominoperineal resection). While most centres perform MRI post chemoradiotherapy, its role in accurate staging post neoadjuvant therapy remains debatable. THe role of Diffusion weighted MRI post neoadjuvant therapy is being evaluated in research settings.

Accuracy of Preoperative MRI in Predicting Pathology Stage in Rectal Cancers

Few studies that meticulously match individual lymph nodes seen on MRI with their precise histologic counterparts after total mesorectal excision have been reported. The objective of this study was to determine whether preoperative MRI could detect lymph node metastases accurately in the node-by-node analysis. This was a prospective, observational cohort study. The study was conducted at a tertiary-care hospital. Forty patients with rectal cancer were enrolled. Specimens were assessed using MRI for clinical staging. After surgical resection of the tumor, the specimens were again imaged with ex vivo ultrasound scan to localize the perirectal node. The locations of each lymph node were precisely matched with its corresponding magnetic resonance image to enable a node-for-node comparison of magnetic resonance images and histologic findings. Agreement between MRI and histologic assessment of T stage was 82.5%. Of the 341 nodes harvested, 120 were too small (<3 mm) to be depicted on magnetic resonance images, and 18 of these contained metastasis (15%). A correlation between the results of MRI and histopathology was feasible for 205 lymph nodes, and the overall success rate of matching between the 2 techniques was 91.1% (205 of 221). Preoperative MRI revealed a node-by-node sensitivity and positive predictive value of 58.0%, and 61.7%. There was no difference in the diagnostic accuracy between the primary surgery subgroup and preoperative radiation subgroups. The study is limited by its heterogeneity of cohorts including the subgroup with preoperative chemoradiation and the lack of preoperative ultrasound assessment. Preoperative MRI was moderately accurate for the prediction of mesorectal lymph node metastasis. Moreover, preoperative MRI was insufficient for detecting small lymph nodes (<3 mm) with metastasis.

Lymphatic Spread of Endometriosis to Para-Aortic Nodes

Endometriosis, “the abnormal growth of endometrial cells,” is a benign, chronic estrogen-dependent gynecologic disease that affects women of reproductive age worldwide [1]. In patients diagnosed with deep infiltrating endometriosis, foci of endometriosis have been detected in mesorectal lymph nodes after bowel resection [2,3].

The importance of not overstaging mesorectal lymph nodes seen on MRI

Colorectal DiseaseVolume 15, Issue 10 p. 1201-1204 Special Article The importance of not overstaging mesorectal lymph nodes seen on MRI M. Chand, M. Chand [email protected] Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT UK Croydon University Hospital, London Road, Croydon, CR7 7YE UKSearch for more papers by this authorR. J. Heald, R. J. Heald Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, RG24 9NN UKSearch for more papers by this authorG. Brown, G. Brown Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT UKSearch for more papers by this author M. Chand, M. Chand [email protected] Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT UK Croydon University Hospital, London Road, Croydon, CR7 7YE UKSearch for more papers by this authorR. J. Heald, R. J. Heald Pelican Cancer Foundation, The Ark, Dinwoodie Drive, Basingstoke, RG24 9NN UKSearch for more papers by this authorG. Brown, G. Brown Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT UKSearch for more papers by this author First published: 24 October 2013 https://doi.org/10.1111/codi.12435Citations: 16 All authors contributed equally to the conception, research and writing of this article. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume15, Issue10October 2013Pages 1201-1204 RelatedInformation

MRI of anal cancer: assessing response to definitive chemoradiotherapy

Anal cancer is an uncommon malignancy of the gastrointestinal tract but has a relatively good prognosis with an 80% 5-year overall survival. In this article, we review the role of MRI for assessing treatment response in anal cancer after completion of definitive chemoradiotherapy. New generation MRI scanners with optimal-phased array body coils, resulting in better signal to noise and improved contrast and spatial resolution, have contributed to high-resolution imaging in clinical practice enabling visualization of relevant anatomy including the sphincter complex, adjacent structures, mesorectal and pelvic lymph nodes with a diameter down to 2mm. Multiplanar, high-resolution T2-weighted and diffusion-weighted sequences have a role in initial locoregional staging of anal SCC, assisting radiotherapy planning, as well as in assessing response to treatment and treatment-related complications.

Tumour diameter is a predictor of mesorectal and mesenteric lymph node metastases in anorectal melanoma

Anorectal melanoma is a rare neoplasm with poor prognosis. The aim of this study was to investigate what clinicopathological factors predict lymph node metastases and to investigate their association with survival. Patients undergoing surgery with curative intent for primary anorectal melanoma in Fudan University Shanghai Cancer Center between 1989 and 2011 were studied retrospectively. The associations between clinicopathological factors and lymph node metastases and prognosis were determined. Forty-three patients underwent a potentially curative resection with a median follow-up of 20 months; the 5-year overall survival rate was 29.6% with median overall survival of 28 months. Tumour diameter > 3 cm was associated with mesorectal and mesenteric lymph node metastases (P = 0.013). Perineural invasion (hazard ratio 5.683; 95% CI 1.978-16.328; P = 0.001) was the only factor that independently predicted survival. Tumour diameter was associated with mesorectal and mesenteric lymph node metastases; therefore, wide local excision may not be appropriate for surgery with curative intent for patients with a tumour diameter ≥ 3 cm. Perineural invasion was an important prognostic factor for anorectal melanoma.