Assessment of HighResolution Magnetic Resonance Imaging on TNM Stage and Circumferential Resection Margin in Rectal Cancer_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

CONG Guanning ^1,2 , QIN Mingwei ¹ , HE Dan ¹ , XIAO Yi ³ , QIU Huizhong ³ , WU Bin ³ , LIN Guole ³

1.Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China;;
2.Department of Radiology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China;;
3.Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China;

Corresponding author：

Keywords：

High-resolution magnetic resonance imaging; TNM staging system; Circumferential resection margin; Mesorectal fascia; Rectal cancer

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Objective To investigate the accuracy of preoperative high-resolution magnetic resonance imaging (MRI) scans to predict tumor stage, lymph node stage, and circumferential resection margin (CRM) involvement.
Methods Between September 2006 and May 2009, 42 patients with histologically proven rectal cancer by the colonoscopic biopsy in Peking Union Medical College Hospital were staged preoperatively using MRI. All of the patients underwent total mesorectum excision (TME) operation within 1 week after MRI examination. The specimens were reported according to the 2002 TNM staging system for primary colorectal cancer of the American Joint Committee on Cancer (AJCC). Concordance between radiologic staging of tumor, local lymph node, and CRM involvement and pathologic reporting was assessed by means of the Kappa statistic.
Results For all of 42 patients, MRI correctly staged the tumor in 36 patients, understaged in 3 patients and overstaged in 3 patients. Statistically, there was a better correlation between pathologic and radiologic tumor staging (Kappa=0.731, P=0.000). MRI correctly staged lymph node status in 31 patients, understaged in 5 patients and overstaged in 6 patients. Statistically, there was a common correlation between pathologic and radiologic lymph node staging (Kappa=0.410, P=0.009). MRI correctly reported the status of the CRM in 40 patients. Statistically, there was the best correlation between pathologic and radiologic reporting of CRM involvement (Kappa=0.829, P=0.000).
Conclusion Preoperative highresolution MRI scans has a good concordance with pathologic tumor stage but common with pathologic lymph node stage. Preoperative highresolution MRI can provide reliable information about CRM and thus help to choose which patient could benefit from the preoperative neoadjuvant therapy.

Citation： CONG Guanning ,QIN Mingwei,HE Dan,XIAO Yi,QIU Huizhong,WU Bin,LIN Guole. Assessment of HighResolution Magnetic Resonance Imaging on TNM Stage and Circumferential Resection Margin in Rectal Cancer. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2010, 17(9): 894-900. doi: Copy

1.	Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009 [J]. CA Cancer J Clin, 2009; 59(4): 225249.
2.	Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues [J]. CA Cancer J Clin, 2008; 58(3): 161179.
3.	Sung JJ, Lau JY, Goh KL, et al. Increasing incidence of colorectal cancer in Asia: implications for screening [J]. Lancet Oncol, 2005; 6(11): 871876.
4.	Cawthorn SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer [J]. Lancet, 1990; 335(8697): 10551059.
5.	Lindmark G, Gerdin B, Pahlman L, et al. Prognostic predictors in colorectal cancer [J]. Dis Colon Rectum, 1994; 37(12): 12191227.
6.	Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer [J]. Lancet, 1986; 1(8496): 14791482.
7.	MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer [J]. Lancet, 1993; 341(8843): 457460.
8.	Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer [J]. Lancet, 1994; 344(8924): 707711.
9.	Williamson PR, Hellinger MD, Larach SW, et al. Endorectal ultrasound of T3 and T4 rectal cancers after preoperative chemoradiation [J]. Dis Colon Rectum, 1996; 39(1): 4549.
10.	Chari RS, Tyler DS, Anscher MS, et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum [J]. Ann Surg, 1995; 221(6): 778786.
11.	Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery [J]. Ann Surg, 2002; 235(4): 449457.
12.	Quirke P, Durdey P, Dixon MF, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision [J]. Lancet, 1986; 2(8514): 996999.
13.	Nagtegaal ID, Marijnen CA, Kranenbarg EK, et al. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit [J]. Am J Surg Pathol, 2002; 26(3): 350357.
14.	Frykholm GJ, Glimelius B, Pahlman L. Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects [J]. Dis Colon Rectum, 1993; 36(6): 564572.
15.	SebagMontefiore D, Stephens RJ, Steele R, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCICCTG C016): a multicentre, randomised trial [J]. Lancet, 2009; 373(9666): 811820.
16.	Brown G, Richards CJ, Newcombe RG, et al. Rectal carcinoma: thinsection MR imaging for staging in 28 patients [J]. Radiology, 1999; 211(1): 215222.
17.	Brown G, Kirkham A, Williams GT, et al. Highresolution MRI of the anatomy important in total mesorectal excision of the rectum [J]. AJR Am J Roentgenol, 2004; 182(2): 431439.
18.	Bissett IP, Fernando CC, Hough DM, et al. Identification of the fascia propria by magnetic resonance imaging and its relevance to preoperative assessment of rectal cancer [J]. Dis Colon Rectum, 2001; 44(2): 259265.
19.	Gualdi GF, Casciani E, Guadalaxara A, et al. Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging: comparison with histologic findings [J]. Dis Colon Rectum, 2000; 43(3): 338345.
20.	Hanski C. Is mucinous carcinoma of the colorectum a distinct genetic entity? [J]. Br J Cancer, 1995; 72(6): 13501356.
21.	Low RN, McCue M, Barone R, et al. MR staging of primary colorectal carcinoma: comparison with surgical and histopathologic findings [J]. Abdom Imaging, 2003; 28(6):784793.
22.	Akasu T, Iinuma G, Fujita T, et al. Thinsection MRI with a phasedarray coil for preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer [J]. AJR Am J Roentgenol, 2005; 184(2): 531538.
23.	Branagan G, Chave H, Fuller C, et al. Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? [J]. Dis Colon Rectum, 2004; 47(8): 13171322.
24.	BeetsTan RG, Beets GL, Vliegen RF, et al. Accuracy of magnetic resonance imaging in prediction of tumourfree resection margin in rectal cancer surgery [J]. Lancet, 2001; 357(9255): 497504.
25.	Simunovic M, Smith AJ, Heald RJ. Rectal cancer surgery and regional lymph nodes [J]. J Surg Oncol, 2009; 99(4): 256259.
26.	Koh DM, Brown G, Temple L, et al. Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations [J]. Eur Radiol, 2005; 15(8): 16501657.
27.	Brown G, Richards CJ, Bourne MW, et al. Morphologic predictors of lymph node status in rectal cancer with use of highspatialresolution MR imaging with histopathologic comparison [J]. Radiology, 2003; 227(2): 371377.
28.	Koh DM, Brown G, Temple L, et al. Rectal cancer: mesorectal lymph nodes at MR imaging with USPIO versus histopathologic findings－initial observations [J]. Radiology, 2004; 231(1): 9199.
29.	Monig SP, Baldus SE, Zirbes TK, et al. Lymph node size and metastatic infiltration in colon cancer [J]. Ann Surg Oncol, 1999; 6(6): 579581.
30.	Kim JH, Beets GL, Kim MJ, et al. Highresolution MR imaging for nodal staging in rectal cancer: are there any criteria in addition to the size? [J]. Eur J Radiol, 2004; 52(1): 7883.
31.	Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery－the clue to pelvic recurrence? [J] Br J Surg, 1982; 69(10): 613616.
32.	Dixon AR, Maxwell WA, Holmes JT. Carcinoma of the rectum: a 10year experience [J]. Br J Surg, 1991; 78(3): 308311.
33.	Enker WE, Thaler HT, Cranor ML, et al. Total mesorectal excision in the operative treatment of carcinoma of the rectum [J]. J Am Coll Surg, 1995; 181(4): 335346.
34.	McCall JL, Cox MR, Wattchow DA. Analysis of local recurrence rates after surgery alone for rectal cancer [J]. Int J Colorectal Dis, 1995; 10(3): 126132.
35.	Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer [J]. Br J Surg, 2002; 89(3): 327334.

1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2009 [J]. CA Cancer J Clin, 2009; 59(4): 225249.
2. Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2008: a review of current American Cancer Society guidelines and cancer screening issues [J]. CA Cancer J Clin, 2008; 58(3): 161179.
3. Sung JJ, Lau JY, Goh KL, et al. Increasing incidence of colorectal cancer in Asia: implications for screening [J]. Lancet Oncol, 2005; 6(11): 871876.
4. Cawthorn SJ, Parums DV, Gibbs NM, et al. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer [J]. Lancet, 1990; 335(8697): 10551059.
5. Lindmark G, Gerdin B, Pahlman L, et al. Prognostic predictors in colorectal cancer [J]. Dis Colon Rectum, 1994; 37(12): 12191227.
6. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer [J]. Lancet, 1986; 1(8496): 14791482.
7. MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer [J]. Lancet, 1993; 341(8843): 457460.
8. Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer [J]. Lancet, 1994; 344(8924): 707711.
9. Williamson PR, Hellinger MD, Larach SW, et al. Endorectal ultrasound of T3 and T4 rectal cancers after preoperative chemoradiation [J]. Dis Colon Rectum, 1996; 39(1): 4549.
10. Chari RS, Tyler DS, Anscher MS, et al. Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum [J]. Ann Surg, 1995; 221(6): 778786.
11. Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery [J]. Ann Surg, 2002; 235(4): 449457.
12. Quirke P, Durdey P, Dixon MF, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision [J]. Lancet, 1986; 2(8514): 996999.
13. Nagtegaal ID, Marijnen CA, Kranenbarg EK, et al. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit [J]. Am J Surg Pathol, 2002; 26(3): 350357.
14. Frykholm GJ, Glimelius B, Pahlman L. Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects [J]. Dis Colon Rectum, 1993; 36(6): 564572.
15. SebagMontefiore D, Stephens RJ, Steele R, et al. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCICCTG C016): a multicentre, randomised trial [J]. Lancet, 2009; 373(9666): 811820.
16. Brown G, Richards CJ, Newcombe RG, et al. Rectal carcinoma: thinsection MR imaging for staging in 28 patients [J]. Radiology, 1999; 211(1): 215222.
17. Brown G, Kirkham A, Williams GT, et al. Highresolution MRI of the anatomy important in total mesorectal excision of the rectum [J]. AJR Am J Roentgenol, 2004; 182(2): 431439.
18. Bissett IP, Fernando CC, Hough DM, et al. Identification of the fascia propria by magnetic resonance imaging and its relevance to preoperative assessment of rectal cancer [J]. Dis Colon Rectum, 2001; 44(2): 259265.
19. Gualdi GF, Casciani E, Guadalaxara A, et al. Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging: comparison with histologic findings [J]. Dis Colon Rectum, 2000; 43(3): 338345.
20. Hanski C. Is mucinous carcinoma of the colorectum a distinct genetic entity? [J]. Br J Cancer, 1995; 72(6): 13501356.
21. Low RN, McCue M, Barone R, et al. MR staging of primary colorectal carcinoma: comparison with surgical and histopathologic findings [J]. Abdom Imaging, 2003; 28(6):784793.
22. Akasu T, Iinuma G, Fujita T, et al. Thinsection MRI with a phasedarray coil for preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer [J]. AJR Am J Roentgenol, 2005; 184(2): 531538.
23. Branagan G, Chave H, Fuller C, et al. Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? [J]. Dis Colon Rectum, 2004; 47(8): 13171322.
24. BeetsTan RG, Beets GL, Vliegen RF, et al. Accuracy of magnetic resonance imaging in prediction of tumourfree resection margin in rectal cancer surgery [J]. Lancet, 2001; 357(9255): 497504.
25. Simunovic M, Smith AJ, Heald RJ. Rectal cancer surgery and regional lymph nodes [J]. J Surg Oncol, 2009; 99(4): 256259.
26. Koh DM, Brown G, Temple L, et al. Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations [J]. Eur Radiol, 2005; 15(8): 16501657.
27. Brown G, Richards CJ, Bourne MW, et al. Morphologic predictors of lymph node status in rectal cancer with use of highspatialresolution MR imaging with histopathologic comparison [J]. Radiology, 2003; 227(2): 371377.
28. Koh DM, Brown G, Temple L, et al. Rectal cancer: mesorectal lymph nodes at MR imaging with USPIO versus histopathologic findings－initial observations [J]. Radiology, 2004; 231(1): 9199.
29. Monig SP, Baldus SE, Zirbes TK, et al. Lymph node size and metastatic infiltration in colon cancer [J]. Ann Surg Oncol, 1999; 6(6): 579581.
30. Kim JH, Beets GL, Kim MJ, et al. Highresolution MR imaging for nodal staging in rectal cancer: are there any criteria in addition to the size? [J]. Eur J Radiol, 2004; 52(1): 7883.
31. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery－the clue to pelvic recurrence? [J] Br J Surg, 1982; 69(10): 613616.
32. Dixon AR, Maxwell WA, Holmes JT. Carcinoma of the rectum: a 10year experience [J]. Br J Surg, 1991; 78(3): 308311.
33. Enker WE, Thaler HT, Cranor ML, et al. Total mesorectal excision in the operative treatment of carcinoma of the rectum [J]. J Am Coll Surg, 1995; 181(4): 335346.
34. McCall JL, Cox MR, Wattchow DA. Analysis of local recurrence rates after surgery alone for rectal cancer [J]. Int J Colorectal Dis, 1995; 10(3): 126132.
35. Wibe A, Rendedal PR, Svensson E, et al. Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer [J]. Br J Surg, 2002; 89(3): 327334.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Assessment of HighResolution Magnetic Resonance Imaging on TNM Stage and Circumferential Resection Margin in Rectal Cancer

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