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Islah Ud Din (ST4 Radiology, Mersey Deanery)Co-authors:
Mr M Thornton (Senior Surgical SPR)
Mr D Vimalachandran (Consultant GI Surgeon)Dr G Abbott (Consultant Radiologist)
RADIOLOGICAL AND PATHOLOGICALCORRELATION OF COLORECTAL CANCERSTAGING
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OBJECTIVES
Background
Method
Results
Conclusion
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BACKGROUND
Pre-op CT traditional role limited to excludesynchronous mets due to limited accuracy
2007...CT can predict outcome, not just pathology
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..for many patients the current treatment strategy of surgical excision
followed by adjuvant chemotherapy still fails either to clear locoregional spread or to eradicate distant micrometastases, leading to diseaserecurrence.Preoperative chemotherapy has been shown to be more effective thanpostoperative chemotherapy in a number of gastrointestinal and othercancers and has the potential to improve outcome in colon cancer. Optimal
systemic therapy at the earliest possible opportunity may be more effectiveat eradicating distant metastases than the same treatment given after thedelay and immunological stress of surgery. Added to this, shrinking theprimary tumour before surgery may reduce the risk of incomplete surgicalexcision, and the risk of tumour cell shedding during surgery..
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FoXTROT Pilot Phase The Lancet Oncology 2012)
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FURTHER WORK
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FURTHER WORK
COLORECTAL DIS. 2012 APR;14(4):438-44. DOI: 10.1111/J.1463-1318.2011.02638.X.
http://www.ncbi.nlm.nih.gov/pubmed/21689323http://www.ncbi.nlm.nih.gov/pubmed/216893238/13/2019 J4 - Radiological and Pathological Correlation of Colorectal Cancer Staging_ Islah Din
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TNM STAGING (BASIC)T STAGE CRITERIA
T1 Tumour invades submucosa
T2 Tumour invades muscularis propria
T3 Tumour invades through the muscularis propria (MP) into thesubserosa, or into nonperitonealized pericolic or perirectal tissues.FoxTROT: Good T3 (
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SURGICAL ANATOMY
The posterior surface of the ascending (anddescending) colon lacks peritoneum
Peritonealised parts of the colon:Caecum
Anterior and lateral surfaces of the ascending (and descending) colon
Transverse colon
Sigmoid colon
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SURGICAL ANATOMY
similar to mesorectal fascia so involvement = T3 with positive margin rather thanT4
tumour beyond MP in peritonealised surface = T4
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SURGICAL ANATOMY
Complete investment of transverse colon (a) and sigmoid colon (b) by peritoneum
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METHOD
Retrospective study
78 patients (March 2009 to June 2011) all patients who hadprimary surgical resection of colonic tumour
Standard TNM staging recorded CT scans read by a generalradiologist who was blinded to the pathology
Data compared with pathology results
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Age, years
Mean (SD) 69 (+/-13)Median (range) 70 (41-90)
Sex
Male 46
Female 32
Tumour site
Rectosigmoid/sigmoid 28
Descending/splenic 12
Transverse/hepatic flexure 13
Ascending/caecum 25pT-stage
1 3
2 4
3 51
4 20
RESULTS
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Histology
MDCT pT1 pT2 pT3 pT4 Total
T1 1 0 1 0 2
T2 2 4 28 3 37
T3 0 0 4 2 6
T4 0 0 18 15 33
Total 3 4 51 20 78
CT PREDICTION OF DEPTH OF INVASIONCOMPARED TO HISTOLOGY
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MDCT pT3/T4 pT1/2 Total
T3/4 39 0 39
T1/2 32 7 39
Total 71 7 78
Sensitivity to detect poor prognostic (T3/T4) tumours = 54.9% (95%CI:42.7-66.8)
Specificity = 100% (58.9-100) Accuracy = 59%
Positive predictive value =100% (90.9-100)Negative predictive value = 18% (7.6-33.5)
Number who may have benefited from neoadjuvant treatment = 71Number potentially randomised to neoadjuvant therapy = 39 (39/71=55%)Number potentially randomised inappropriately = 0
Number under staged and excluded inappropriately = 32 (32/71=45%)
CT PREDICTION OF HIGH-RISK COLONCANCER BASED ON DEPTH OF INVASION
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Location
Correct stage(n)
Over-staged(n)
Under-staged (n)
Total
Caecum/ascending 48%(12) 24% (6) 28% (7) 25
Hepaticflexure/transverse
23% (3) 31% (4) 46% (6) 13
Splenicflexure/descending
25% (3) 8% (1) 67% (8) 12
Sigmoid/rectosigmoid 21% (6) 32% (9) 46%(13) 28
ACCURACY OF T STAGING BY LOCATION OFTUMOUR
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MDCT pN1/2 pN0 Total
N1/2 10 13 23
N0 20 35 55
Total 30 48 78
Sensitivity to detect positive LN= 33.3% (95%CI:17.3-52.8)
Specificity = 72.9% (58.2-84.7)
Accuracy = 57.7%
Positive predictive value =43.5% (23.2-65.5)
Negative predictive value = 63.6% (49.6-76.5)
ACCURACY OF CT TO PREDICT NODALDISEASE
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EXAMPLES
Gross specimen of T4 tumours
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EXAMPLES
Same T stage on pathology and CT
T2 T3
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EXAMPLES
Same T stage on pathology and CT
T4T4
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EXAMPLES
Different T stage on pathology and CT
CT (T2)
pT3 pT3
CT (T2)
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EXAMPLES
Different T stage on pathology and CT
pT3
CT (T4)
pT3
CT (T4)
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EXAMPLES OF POSITIVE NODES ON CTCONFIRMED HISTOLOGICALLY
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LIMITATIONS
CT read by one radiologist
CT not read by GI radiologist
CT technique was not standardised (CT colon protocol was notfollowed in all cases)
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CONCLUSION/ SUMMARY
100% specificity in that we did not overcall T1/2 as higherstage. Over staging these would potentially expose the patientsto unnecessary pre-op chemotherapy/ toxicity.
We acknowledge that CT has its limitations as a stagingmodality and good results are obtainable in expert hands intrials but trials do not reflect real world practice.
This study does show that a general radiologist can make goodcalls and the results reflect general day to day practice.
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THANK YOU