J4 - Radiological and Pathological Correlation of Colorectal Cancer Staging_ Islah Din

8/13/2019 J4 - Radiological and Pathological Correlation of Colorectal Cancer Staging_ Islah Din

1/28

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


2/28

OBJECTIVES

Background

Method

Results

Conclusion


3/28

BACKGROUND

Pre-op CT traditional role limited to excludesynchronous mets due to limited accuracy

2007...CT can predict outcome, not just pathology


4/28

..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..


5/28


6/28

FoXTROT Pilot Phase The Lancet Oncology 2012)


7/28

FURTHER WORK


8/28

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/21689323


9/28

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 (


10/28

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


11/28

SURGICAL ANATOMY

similar to mesorectal fascia so involvement = T3 with positive margin rather thanT4

tumour beyond MP in peritonealised surface = T4


12/28

SURGICAL ANATOMY

Complete investment of transverse colon (a) and sigmoid colon (b) by peritoneum


13/28

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


14/28

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


15/28

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


16/28

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


17/28

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


18/28

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


19/28

EXAMPLES

Gross specimen of T4 tumours


20/28

EXAMPLES

Same T stage on pathology and CT

T2 T3


21/28

EXAMPLES

Same T stage on pathology and CT

T4T4


22/28

EXAMPLES

Different T stage on pathology and CT

CT (T2)

pT3 pT3

CT (T2)


23/28

EXAMPLES

Different T stage on pathology and CT

pT3

CT (T4)

pT3

CT (T4)


24/28

EXAMPLES OF POSITIVE NODES ON CTCONFIRMED HISTOLOGICALLY


25/28

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)


26/28


27/28

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.


28/28

THANK YOU

J4 - Radiological and Pathological Correlation of Colorectal Cancer Staging_ Islah Din

Documents

Transcript of J4 - Radiological and Pathological Correlation of Colorectal Cancer Staging_ Islah Din