Rectal cancer: Prediction of pulmonary metastasis on thoracic CT correlated with tumor location using highresolution

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1 Rectal cancer: Prediction of pulmonary metastasis on thoracic CT correlated with tumor location using highresolution 3T rectal MRI Poster No.: C-1563 Congress: ECR 2010 Type: Topic: Authors: Keywords: DOI: Scientific Exhibit GI Tract N. Y. Han, M. J. Kim, B. J. Park, D. J. Sung, K. B. Chung, Y.-W. Oh; Seoul/KR rectal cancer, location, pulmonary metastases /ecr2010/C-1563 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 14

2 Purpose Venous drainage is mainly by portal route in upper portion of rectum and by systemic route in lower portion of rectum. Page 2 of 14

3 Fig.: Venous drainage from the rectum. The superior rectal vein drains the upper and middle thirds of the rectum. They mainly empty into the portal system via the inferior Page 3 of 14

4 mesenteric vein. The middle rectal veins drain the lower rectum and the upper anal canal into the systemic system via the internal iliac veins. References: The McGrav-Hill companies, Inc. Based on this anatomic background, we form the hypothesis that the incidence of pulmonary metastasis will be higher in lower rectal cancer than upper rectal cancer. The purpose of this study was to evaluate the association between the incidence of pulmonary metastases and the location of rectal cancer. Methods and Materials Patient From July 2007 to March patients with confirmed to rectal carcinoma (76 men, 33 women; mean age, 62.3 years; range, 30~97 years) They performed chest CT and high-resolution rectal MRI using 3T scanner within three weeks before treatment Histopathologic classification of the tumors ; Carcinoma arising in an adenoma(n=2); well-differentiated adenocarcinoma(n=51); moderate-differentiated adenocarcinoma(n=49); pooly-differentiated adenocarcinoma(n=2); mucinous adenocarcinoma(n=3) ; not available (n=1) Imaging technique Patient preparation - Bowel preparation: rectal cleansing using sodium phosphate enema - In the MR room, 150~250ml warm saline injected - Intravenous antisperistaltic agent MR technique - 3-T MRI unit (Siemens Trio Tim, Erlangen, Germany) - Surface flexible coil (Flex Large; Siemens Medical Systems) Page 4 of 14

5 - Axial, coronal, sagittal T2 weighted images; axial T1 weighted image CT technique - 4 slice scanner (Volume Zoom; Siemens Medical Solutions, Iselin, NJ); 64 slice scanner (Brilliance 64, Philips Medical Systems, Cleveland, Ohio) - Contrast enhancement; 100ml, 2.5ml/sec Image review Two reviewers: One abdominal specialist and one 2 nd year trainee 1. Rectal MR a) Location of the tumor in rectal MRI (Fig.1) - Each reviewers classified the location of the tumor into three parts :upper (10-15cm from anal verge), mid (5-10cm), and lower (<5cm) b)local tumor staging of the tumor in rectal MRI - TNM staging 2. Chest CT (Fig.2) - Positive for pulmonary metastastasis; parenchymal lung nodule (#1cm if single and 0.5cm if multiple) with a soft tissue component without calcification Statiscal analysis The Statistical Package for Social Sciences (SPSS), version 8 for statistical analysis Fisher's exact test and Mantel-haenszel test used Statistical significancy: p-value of <.05 Images for this section: Page 5 of 14

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7 Fig. 1: The method we used for deciding the location of the tumor. Each reviewer draw a line along the midline of rectal lumen and distance from the lower margin of a rectal tumor to the anal verge was measured in zigzag pattern on saggital T2 weighted image. Sagittal T2-weighted images were primarily used. Page 7 of 14

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9 Fig. 2: Axial chest CT scan of the patient who was considered to have metastatic lung nodule. The size of the lung nodules were measured on lung window setting (window level, -649; window width, 1400) and then setting was changed to mediastinal window (window level, 45; window width, 440) to exclude the calcified granuloma. Page 9 of 14

10 Results Of the 109 patients, two patients were excluded from the statistical analysis because the measured distance was over 15 centimeter. Among 107 patients(74 men, 33 women; mean age, 62.3 years; range, 30~97 years), the location of the tumor and the incidence of the pulmonary metastasis is like this. Fig.: Number of patients in each location of tumor. References: N. Y. Han; Radiology, Korea University, College of Medicine & Hospital, Seoul, KOREA, Republic of Among these patients, the patients with mid location of tumor were excluded from statistic analysis because of various venous drainage. The incidence of pulmonary metastasis in lower rectal cancer was higher than in upper rectal cancer but it was not statistically significant (P=.064 >.05). We used two statistical methods to exclude the effect of local tumor staging 1. Fisher's exact test is applied to four sub-groups divided by radiologic T- staging ; Only in stage III lesions, the incidence of pulmonary metastasis in distal rectal cancer is significant higher(p=.048) Page 10 of 14

11 Fig.: Fisher's exact test applied to each group of radiologic T stage. References: N. Y. Han; Radiology, Korea University, College of Medicine & Hospital, Seoul, KOREA, Republic of 2. Mantel-Haenszel test is used to control the effect of T staging ; The incidence of the pulmonary metastasis was significant higher in lower rectal cancer when local tumor staging is controlled (P=.041<.05) Conclusion Limitation Retrospective study Small sample number Not obtained histopathological confirmation or long term follow-up of pulmonary metastasis Conclusion Page 11 of 14

12 The incidence of pulmonary metastasis in rectal cancer is significantly higher in lower rectal cancer when radiologic local tumor staging is controlled. Preoperative chest CT scan must be emphasized especially in lower rectal cancer References 1. Gielen C, Sanli I, Stroeken L, Botterweck A, Hulsewe K, Hoofwijk A. Staging chest radiography is not useful in patients with colorectal cancer. Eur J Surg Oncol 2009; 35: Chartrand-Lefebvre C, Lapointe R, Samson L, Cordeau MP, Prenovault J. Chest computed tomography screening in colorectal cancer patients. World J Surg 2009; 33: ; author reply Tjandra JJ, Kilkenny JW, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 2005; 48: Sakamoto T, Tsubota N, Iwanaga K, Yuki T, Matsuoka H, Yoshimura M. Pulmonary resection for metastases from colorectal cancer. Chest 2001; 119: Doherty GM, Way LW. Current surgical diagnosis & treatment. New York: Lange Medical Books/McGraw-Hill, Zhang XM, Zhang HL, Yu D, et al. 3-T MRI of rectal carcinoma: preoperative diagnosis, staging, and planning of sphincter-sparing surgery. AJR Am J Roentgenol 2008; 190: Taylor FG, Swift RI, Blomqvist L, Brown G. A systematic approach to the interpretation of preoperative staging MRI for rectal cancer. AJR Am J Roentgenol 2008; 191: Page 12 of 14

13 8. Kirke R, Rajesh A, Verma R, Bankart MJ. Rectal cancer: incidence of pulmonary metastases on thoracic CT and correlation with T staging. J Comput Assist Tomogr 2007; 31: Penna C, Nordlinger B. Colorectal metastasis (liver and lung). Surg Clin North Am 2002; 82: , x-xi. 10. Barlow AD, Nakas A, Pattenden C, et al. Surgical treatment of combined hepatic and pulmonary colorectal cancer metastases. Eur J Surg Oncol 2009; 35: McAfee MK, Allen MS, Trastek VF, Ilstrup DM, Deschamps C, Pairolero PC. Colorectal lung metastases: results of surgical excision. Ann Thorac Surg 1992; 53: ; discussion Eriksen MT, Wibe A, Haffner J, Wiig JN. Prognostic groups in 1,676 patients with T3 rectal cancer treated without preoperative radiotherapy. Dis Colon Rectum 2007; 50: Grinnell RS. The spread of carcinoma of the colon and rectum. Cancer 1950; 3: Koch M, Weitz J, Kienle P, et al. Comparative analysis of tumor cell dissemination in mesenteric, central, and peripheral venous blood in patients with colorectal cancer. Arch Surg 2001; 136: Kronawitter U, Kemeny NE, Heelan R, Fata F, Fong Y. Evaluation of chest computed tomography in the staging of patients with potentially resectable liver metastases from colorectal carcinoma. Cancer 1999; 86: National Comprehensive Cancer Network (U.S.). Clinical Practice Guidelines in Oncology - v In ed. Rockledge, PA: NCCN, 2009; 1 CD-ROM. 17. Van Cutsem E, Oliveira J. Primary colon cancer: ESMO clinical recommendations for diagnosis, adjuvant treatment and follow-up. Ann Oncol 2009; 20 Suppl 4: Kim CK, Kim SH, Chun HK, et al. Preoperative staging of rectal cancer: accuracy of 3-Tesla magnetic resonance imaging. Eur Radiol 2006; 16: Personal Information Na Yeon Han Department of Radiology Korea University Anam hospital Page 13 of 14

14 mammos2000@daum.net Min Ju Kim Department of Radiology Korea University Anam hospital dr.minjukim@gmail.com Page 14 of 14