All along the colon: multimodality imaging and staging

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1 Satellite Symposium ESGAR 2011 All along the colon: multimodality imaging and staging Chairman: Prof. T. Lauenstein (Essen Germany) Invitation Sunday, May 22 nd, :00-14:00 Venice Convention Centre, Lido, Italy Sala Laguna, level 3

2 Introduction by the chairman Prof.T. Lauenstein (Essen Germany) Potential of multimodality approach in colon imaging Cross sectional imaging including computed tomography (CT) and magnetic resonance tomography (MRI) is nowadays widely used in the field of gastrointestinal imaging. Both tumor and inflammatory disease of the bowel can be accurately visualized by means of CT and MRI. In spite of the competition with other diagnostic modalities including (capsule) endoscopy, there are considerable advantages associated with cross sectional imaging. Not only changes of the mucosa can be assessed, but all bowel layers and also extraintestinal diseases can be evaluated. This is of particular interest in inflammatory bowel disease for the depiction of fistulae and abscesses and in malignant diseases for tumor staging and the visualization of lymph nodes or hepatic metastases. The three presentations will provide an overview over different clinical applications of CT and MRI for the assessment of the small bowel, colon and rectum.

3 Bowel preparation in CT colonography for a better patient compliance CT colonography is potentially the most accurate non-invasive method to detect colorectal polyps and cancers. Many clinical studies evaluating CT colonography have demonstrated a success rate of 75 to 100% in detecting colorectal polyps 1cm or more in diameter. CT colonography requires a clean, dry and distended colon for optimal detection. Prior to the examination, a bowel preparation is required. The inconvenience and discomfort of this procedure greatly reduce patient compliance. The traditional bowel preparation for CT colonography, includes a low -residue diet, and a cathartic cleansing (sodium phosphate or magnesium citrate and bisacodyl tablets) the day before the examination. However, residual stool or fluid residue appear on CT hypodense, and may mimic polyps or hide colic lesions. Fecal tagging (barium and/or iodine) administrated orally 24 hours prior to examination is used as stool markers. Residual stool and fluid appear hyperdense on CT. Fecal tagging improves the detection of retained stool and allows differentiation of stool from colonic polyp. Electronic cleansing is an emerging technique for the removal of tagged fecal residue from CT colonographic images. This technique seems to be helpful for radiologist, by improving interpretation time. Association of low residue-diet, cathartic cleansing, and fecal tagging is essential to perform state-of the-art CT colonography and is currently considered the clinical standard preparation. Disadvantages of the cathartic preparation are related to side effects, impact on patient s tolerance and acceptance of the examination. This is the major barrier in colorectal cancer screening. Recently, limited bowel preparation using low- fiber or clear diet combined with an ingestion of oral contrast (barium or iodine) in divided doses has been proposed to increase patient compliance. Reduction or elimination of catharsis with fecal tagging enhances the tolerability of CT colonography. In the future, a taggingonly bowel preparation for CT colonography might be a challenge to enhance patient compliance especially in colorectal cancer screening. Marie-Ange Pierredon Foulongne MD Imagerie Médicale, CHU Montpellier Montpellier, France

4 MRI in locoregional assessment of rectum cancer Rectal cancer is one of the most common malignant tumours. One concern after rectal cancer surgery is the high local recurrent rate. In recent years mortality rates have decreased due to major changes in therapeutic management, especially the operative procedure and the introduction of neoadjuvant therapy. Neoadjuvant therapy followed by total mesorectal excision is now used as a standard for the majority of patients with locally advanced rectal cancer in attempt to reduce the rate of local recurrence. This presentation aims to illustrate the impact of MRI on the diagnosis and management of patients with rectal cancer. It will provide an overview of the use of this technique at initial diagnosis and follow-up. MR preoperative imaging in staging the local extent of primary rectal cancer is important in order to select subgroups of patients most likely to benefit from neoadjuvant therapy. The most relevant aspects of local spread of rectal tumours will be discussed: T stage, circumferential resection margin and N stage. Research on various MRI modalities that address nodal malignancy prediction will be presented. MR restaging of rectal cancer after concurrent chemotherapy and radiation therapy is challenging. Awareness of therapeutic changes helps radiologists achieve appropriate restaging. The contribution and limitations of MR after chemoradiation therapy will also be discussed. Céline Savoye-Collet MD Imagerie Médicale, CHU Charles Nicolle Rouen, France

5 The role of CT Enteroclysis in peritoneal carcinomatosis Cytoreductive Surgery (CRS) combined with Perioperative Intraperitoneal Chemotherapy (PIC) has resulted in improved long-term disease control rates in selected patients with peritoneal carcinomatosis (PC) of various origins, previously considered only for palliative treatment approaches. Disease in the small bowel (SB) constitutes a sentinel, limiting criterion in the decision making process involved CRS because enough SB needs to remain in place to allow for an adequate oral nutrition in the future. Thus evaluation of SB is crucial component in the preoperative imaging assessment. Experience tells us that even the most sophisticated CT technology usually underestimates actual SB involvement revealed at surgical exploration. CT-Enteroclysis (CTE) may be indicated as complementary tool in the diagnostic work-up evaluation of patients with PC candidates for an adequate CRS since it could map in detail and accurately the extend of the disease in the SB and its mesentery. The use of scanners with higher spatial resolution might increase our ability to detect smaller and thinner cancerous implants. Further studies in larger cohorts are needed to establish CTE as initial work-up evaluation in this specific group of patients since it combines diagnostic data from a conventional abdominal CTscan and simultaneously describes the extend of the disease in the SB and its mesentery References Dromain C, Abdom Imaging 2008; 87 Jacquet P, J Am Coll Surg 1995;530 Gonzalez-Moreno S, Cancer J 2009 Yan TD, et al. Ann Oncol 2007 Yan TD, et al. Ann Surg Oncol 2007 Yonemura Y, et al. Cancer Treat Res 2007 Nikos Courcoutsakis, MD, D(Med)Sci Democritus University of Thrace, Alexandroupolis, Greece

6 All along the colon: multimodality imaging and staging Chairman Prof. T. Lauenstein (Essen Germany) 13:00-13:10 13:10-13:25 Introduction: potential of multimodality approach in colon imaging by the Chairman CT enteroclysis in peritoneal carcinomatosis Dr. N. Courcoutsakis (Alexandropoulis, Greece) 13:25-13:40 13:40 13:55 Bowel preparation in CT colonography for a better patient compliance Dr. M. A. Pierredon Foulongne (Montpellier, France) MR Imaging in loco-regional assessment of rectum cancer Dr. C. Savoye Collet (Rouen, France) 13:55 14:00 Conclusion by the Chairman Citron Marine - April P TX Guerbet - 15, rue des Vanesses Villepinte Guerbet - BP Roissy CdG Cedex

Index. Surg Oncol Clin N Am 16 (2007) Note: Page numbers of article titles are in boldface type.

Index. Surg Oncol Clin N Am 16 (2007) Note: Page numbers of article titles are in boldface type. Surg Oncol Clin N Am 16 (2007) 465 469 Index Note: Page numbers of article titles are in boldface type. A Adjuvant therapy, preoperative for gastric cancer, staging and, 339 B Breast cancer, metabolic