This presentation is provided as a courtesy of
Gina Brown to the participants of the
Masterclass in Colorectal Surgery of the
European Colorectal Congress 2014
for their personal use
h
Please refrain from any unauthorized use
© Gina Brown - 2014
Michel Adamina, MD, PD, MSc
Masterclass & Congress Organization
www.colorectalsurgery.eu
The Royal Marsden
Rectal Carcinoma Staging:
A Practical Approach
Gina Brown
Royal Marsden Hospital
and Imperial College
[email protected] Assessing rectal cancer:
a practical approach
• Which technique to use?
• Assessing prognostic features/evidence base
• Reporting scans for oncology planning
• Reporting scans for surgical management
• Assessing response to treatment and DWI
• Clinical trials and future research
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Which of these best
reflects your practice staging
rectal cancer?
1. CT and EUS +/- PET-CT are staging
modalities of choice at my institution
2. MRI is sometimes/frequently used for
staging rectal cancer
3. MRI is mandatory for rectal cancer staging
at my institution
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Which types of scans do you look at?
1. Fat sat T1 with dynamic contrast
2. Small field of view T2 FSE
3. STIR, T2 fat sat
1 2 3
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T1 sequence for rectal cancer
What stage is this tumor?
• 1. T1
• 2. T2
• 3. T3
• 4. Wouldn’t like to say
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T1 sequences for rectal cancer
little useful information!
Field of view too big,
cannot resolve tumor
well T1 tumor and vessels are not
distinguished leads to overstaging
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Learning from Pathology
Mesorectal fascia Depth of spread/mm
Slice 1 Slice 2
Slice 2
Slice 1
Distance to CRM Lymph
nodes
vessels
Slice 3 Slice 4 Slice 3 Slice 4
Slice 5
Slice 6 Slice 6
Slice 5
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Surface Coil Position/Selection
Surface Coil has been Correct positioning
placed too high
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Incorrect positioning
Correct positioning
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MDT review of MRIs
• Local excision or TME?
• TME plane safe?
• Extended operation needed?
• Sphincter conservation possible?
• Is preoperative therapy needed?
T staging of early lesions
• How would you
have chosen to
stage this lesion
• 1. EUS
• 2. MRI
• 3. preop staging
unecessary
T staging of early lesions
T staging of early lesions
• How would you
chosen to stage this
lesion
• 1. EUS
• 2. MRI
• 3. preop staging
unecessary
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MRI is better for early stage
polypoidal lesions
EUS limitations
• T3 good prognosis vs poor not distinguished – overtreatment by
preop CRT
• Mesorectal margin not visualised
• Only immediate perirectal nodes assessed
• Stenosing tumours
• Overstaging of polypoidal/villous lesions:
EUS-based evaluation alone cannot determine the appropriate
treatment for colorectal villous lesions.” Konishi et al 2003
German RT trials – 18% T1 and T2 tumors staged as advanced T3 by
EUS
Understanding rectal
tumor invasion
Can you see high signal submucosa =
yes =T1
Cannot see submucosa but can see
low signal muscularis = T1 sm3/T2
Cannot see full thickness of muscularis
propria but tumor does not project
beyond contour =T2 full thickness or
T3<1mm
Tumour projects beyond muscularis
propria =T3
T2 tumor
What is the T stage of this
tumor?
1. T1 confined to submucosa • insert slide of burg
2. T2 0mm spread
3. T2/T3a <1mm spread
4. T3b 1-5mm spread
5. T3c >5mm
What is the T stage of this
tumor?
1. T1 confined to submucosa • insert slide of burg
2. T2 0mm spread
3. T2/T3a <1mm spread
4. T3b 1-5mm spread
5. T3c >5mm
6. T4
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Which tumours are at risk of
pelvic recurrence after TME?
1 2
3
1. all 3 4. Case 3
2. Case 1 5. Cases1 and 2
3. Case 2 6. Cases2 and 3
pT3<5mm, N any
•T2 and early T3
tumours <5mm have
85-90% 5 year cancer
specific survival.
MERKEL et al 2001
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CRM is safe if distance of tumour to mesorectal fascia is >1mm
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Is the potential CRM involved?
1. Yes
2. No
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The peritoneal reflection is not a
potential circumferential margin
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Is the CRM involved?
1. Yes
2. No
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Nodal anatomy
Afferent lymphatic
Efferent lymphatics and
vessels
Medullary sinus
Follicle
Marginal sinus
Capsule
Courtesy of DM Koh
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Nodal anatomy
Afferent lymphatic
Efferent lymphatics and vessels
Medullary sinus
Follicle
Capsule
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Lymph node border and intensity –
measuring nodes is NOT ecommended
• node positive if either irregular border or mixed signal intensity
was demonstrated, the sensitivity, specificity were high.
• Metastases were demonstrated in 51/56 nodes (91%, 95% CI
81% to 96%) with either an irregular border or a mixed intensity
signal.
• only 9/225 nodes (4%, CI 2.1% to 7.4%) with smooth borders
and a uniform signal contained metastases.
• Size of node bears no relationship to malignant risk
Brown et al Radiology 2003
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Malignant node
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Is this 6mm node benign or
malignant?
1. Benign
2. Malignant
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Is this a benign
or malignant node?
• 1. benign: smooth low
signal capsule, uniform
signal intensity of node
• 2. malignant: capsule
breached, internal
signal heterogenous
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Benign or malignant
• 1. benign: smooth low
signal capsule, uniform
signal intensity of node
• 2. malignant: capsule
breached, internal
signal heterogenous
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Is this a benign
or malignant node?
Field of view (FOV) 22cm x 22cm Field of view (FOV) 16cm x 16cm
Slice thickness 3mm Slice thickness 3mm
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The “bad” tumours
• T3>5mm, N0-N2
• Extramural venous invasion
• T2 full thickness/T3a tumours at
sphincter level
Extramural venous invasion
Irresectable liver metastases developed after 1 year
EMVI detection by MRI
EMVI is Present in 30%-40% of rectal cancer patients
MRI is accurate in the pre-operative detection of EMVI.
Histology of ‘nodule’ shows some
microscopic EMVI (black arrows) and
Upper rectal tumour (red arrow)
tumour filling lumen of larger vessel
+ separate ‘nodule’ in superior
rectal vein (green arrow)
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Histological EMVI status & Outcome
n=135. Median follow-up=3·12 (0·9-5·7) years.
100 Histological EMVI-
Histological EMVI+
80
73%
% Relapse-free
60
40 p < 0·00001
28%
20
0
0 1 2 3 4 5 6
Time since operation (Years)
“Prognostic significance of MRI-detected Extramural Vascular Invasion." BJS. 2008
MRI-EMVI score & Outcome
n=135. Median follow-up=3·12 (0·9-5·7) years.
MRI-EMVI score= 0-2
100 MRI-EMVI score= 3-4
80
% Relapse-free
71%
60
40 p = 0·0015
32%
20
0
0 1 2 3 4 5 6
Time since operation (Years)
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T3 tumours >5mm spread 54%
5 year cancer specific survival
Merkel et al 2001
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What does this show?
• 1. T3d disease
• 2. EMVI
• 3. positive lymph
nodes
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A
TRG
B
1 C
Radiological complete response (rCR) – linear
dense low signal intensity scar that does not
alter on serial imaging
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TRG 2
Good response (dense fibrosis; no obvious
residual tumour, signifying microscopic residual
disease only and on continued surveillance may
become TRG1 no viable tumor)
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TRG 3
• Moderate
response (>50%
fibrosis or mucin,
and visible
intermediate
signal)
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Diffusion weighted imaging in
rectal cancer
• Routine assessment
• Non-invasive additional sequence
• Does not improve staging accuracy for TNM
• Does not add anything to mrTRG assessment
post treatment
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Assessing response after
Chemoradiotherapy
Locally Advanced Rectal Cancer: added Value of Diffusion-
weighted MR imaging in the Evaluation of Tumor
Response to Neoadjuvant Chemo andRadiation Therapy
Kim et al Radiology 2009
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Analysis of Diffusion-weighted MR imaging for Early
Detection of Tumor histopathologic Downstaging
Sun et al Radiology 2010
• Baseline ADC lower than non
downstaged group :1.07 x 10-3 vs
1.19 x 10-3
• DWI in 1st week of CRT: mean
tumor ADC increased from 1.07 x
10-3 to 1.32 x 10-3 in downstaged
group
• no significant ADC increase in the
non-downstaged group
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Are results generalisable?
• TME surgery
• Standardised High
resolution MRI
• Quality control
histopathology
• MDT discussion:
individualised treatment
strategy
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MERCURY Study
Ashford St Peters Hospital, England
Epsom General Hospital, England
Frimley Park Hospital, England
Mayday University Hospital, England
Karolinska Institute, Sweden
Krankenhaus Friedrichshain, Germany
Leeds General Infirmary, England
Llandough Hospital, Wales
North Hampshire Hospital, England
National Radium Hospital, Norway
Royal Marsden Hospital, England
St James’ University Hospital, England
Reporting Minimum Standards
Baseline assessment of Rectal cancer MRI report
Primary tumour Lymph node assessment
The primary tumour is demonstrated as an [ Annular | Semi-annular | Ulcerating | | Polypoidal | Only benign reactive and no suspicious nodes shown [N0]
Mucinous] mass with a [nodular / smooth] infiltrating border. [ ] mixed signal/irregular border nodes [N1/N2]
Extramural venous invasion: [ No evidence ] [ Evidence]
The distal edge of the luminal tumour arises at a height of [ ] mm from anal verge: [ ] Small [ ]Medium [ ]Large vein invasion is present
The distal edge of the tumour lies [ ]mm [Above,at, below] the top of the puborectalis sling CRM
The tumour extends craniocaudally over a distance of [ ] mm The closest circumferential resection margin is at o’clock
The proximal edge of tumour lies [above at below] the peritoneal reflection The closest CRM is from [Direct spread of tumour] [Extramural venous invasion] [Tumour
Invading edge of tumour extends from [ to ] O’clock deposit]
Tumour is [confined to] [extends through] the muscularis propria: Minimum tumour distance to mesorectal fascia: mm [CRM clear ] [CRM involved]
Extramural spread is [ ] mm Peritoneal deposits: [ No evidence] [ Evidence]
Pelvic side wall lymph nodes:
mrT stage: [T1 ] [ T2 ] [ T3a] [ T3b ] [ T3c] [ T3d ] [T4visceral ] [T4
[ None] [ Benign] [ Malignant mixed signal/irreg border]
peritoneal] Location: [Obturator fossa • R •L ] . [External Iliac Nodes • R •L] .[ Internal iliac • R •L ]
Tumour is [present] [not present] the level of the puborectalis sling at this level: Summary: MRI Overall stage: T N M [CRM clear] , [ CRM involved ] , [ EMVI
[Tumour is confined to the submucosal layer/part thickness of muscularis propria indicating that the positive] [EMVI negative],[PSW positive ] [PSW negative]
intersphincteric plane/mesorectal plane is safe and intersphincteric APE or ultra low TME is No adverse features eligible for primary surgery
possible] Poor prognosis safe margins for preoperative therapy : eligible for 6 vs 12 trial
[Tumour extends through the full thickness of the muscularis propria : intersphincteric Poor prognosis unsafe margins eligible for preoperative chemoradiotherapy: eligible for 6 vs 12
plane/mesorectal plane is unsafe, Extralevator APE. is indicated for radial clearance] trial
[Tumour extends into the intersphincteric plane : intersphincteric plane/mesorectal plane is unsafe, Low Rectal <6cm – eligible for the Low Rectal Study.
therefore an extralevator APE. is indicated for radial clearance]
[Tumour extends into the external sphincter : intersphincteric plane/mesorectal plane is unsafe.]
[ Tumour extends into adjacent [prostate/vagina/bladder/sacrum] : exenterative procedure will be
required
Additional comments:
.
Take home messages
Technical issues
• Make sure that your imaging protocols
use high resolution T2 weighted
imaging
• Oblique imaging so that scans are
always perpendicular to invasive edge
of tumour
• Large field of view or wrong angles will
reduce accuracy
Take home messages
Technical issues
• Use proformas to report surgical and oncological
prognostic factors – mrT3 substage, mrnode, mrEMVI,
mrCRM, mrlow rectal classification, post treatment
TRG
• Diffusion weighted imaging not validated regarding
prognostic importance
• Anatomical assessment of mrCRM status is THE most
important factor influencing risk of pelvic recurrence
• Identifying patients with safe margins and absence of
risk factors for distant disease – will improve
outcomes and reduce morbidity of patients who would
otherwise have been irradiated
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MRI based clinical trials
Local excision
Deferral of surgery
MRI based
Selection
of patients Timing of surgery
For range after CRT
treatments
Biological agents and neoadjuvant
chemotherapy for MRI EMVI
Extended surgery for CRM/low rectal
Phase III combination CRT for CRM
Deferral of surgery, W & W
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2007
2010
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Low rectal cancer trial
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MRI identified EMVI positive
Frozen – Tissue for gen expresión profiling
XELOX-Bevacizumab x 3
XELOX x 1
MRI/US Re-staging 3 w.
Not Response
Response Not candidate RO
Candidate RO (Surgeon)
TME Surgery RT/CT
GEMCAD trial group 2008
XELOX x 4
Recomended
Course Details from :
[email protected] The Royal Marsden
Acknowledgements:
• Pelican Cancer Foundation
• European Mercury Study Group: Prof Bill Heald, Brendan Moran,
Phil Quirke, I Swift, P Tekkis, S Stelzner, G Branagan, M
Gudgeon, J Strassburg, S Laurberg, T Holm
• Radiologists in MERCURY I and II: Nicola Bees, Helena Blake,
Rob Bleehan, Lennart Blomqvist, Alan Chalmers, Mike Creagh,
Hanne-Linne Emblemsvaag, Sarah Evans, Ashley Guthrie, Chris
George, Knut Håkon Hole, Nick Hughes, Shaun McGee, Petra
Knuth, Delia Peppercorn, Clemens Schubert, Andrew
Thrower,Turid Vertrus
• Research fellows, Sarah Burton, Neil Smith, Gisella Salerno, Fiona
Taylor, Shwetal Dighe, Oliver Shihab, Peter How, Uday Patel,
Jessica Evans, Chris Hunter, Panagiotis Georgiou, Vera Tudyka,
Rafay Siddiqui, Jemma Bhoday, James Read, Manish Chand,
Anita Wale, Alistair Slesser, Nick Battersby, Svetlana Balyasnikova
This presentation is provided as a courtesy of
Gina Brown to the participants of the
Masterclass in Colorectal Surgery of the
European Colorectal Congress 2014
for their personal use
h
Please refrain from any unauthorized use
© Gina Brown - 2014
Michel Adamina, MD, PD, MSc
Masterclass & Congress Organization
www.colorectalsurgery.eu
