Transcript Madina Presentation1

Accuracy of EUS in
diagnosis of rectal cancer
KKUH experience
A.Aljebreen ,N. Azzam , S.
Sharqawi,A.Alzubaidi,T.Alturiki
Colorectal cancer is the most common
gastrontestinal malignancy and the second
cause of cancer-related deaths in West
countries
. Colorectal cancer represents an important
health problem in western countries, with
an increasing incidence in our area
over the last few years.
The prognosis of rectal cancer is related to
several factors, such as
depth of tumoral invasion, number of
metastatic lymph nodes, involvement of
circumferential margin
Preoperative staging is of great
importance for adequate
management.
Recent data have shown that preoperative
radiation therapy can reduce tumor recurrence
from 27% to 11% and improve the survival
accurate local staging information is paramount for
stratifying patients who would benefit from
neoadjuvant therapy as well as for predicting
the surgical approach .
Improved survival with preoperative radiotherapy in
resectable rectal cancer. Swedish Rectal Cancer Trial.
NEngl JMed 1997;336:980^7
.
EUS
 CT SCAN
 MRI with endorectal coil

EUS
Several studies have shown a high accuracy
rate of endoscopic ultrasound (EUS) in the
preoperative staging of rectal cancer.
These studies reported an overall accuracy
of 83% (75−90%) for T stage and 75%
(65−80%) for N stage.
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Bartram C. Gastroenterol Clin North Am 2002; 31: 827-39.
Fusaroli P. Eur J Gastroenterol Hepatol 2005; 17: 293-301.
EUS Accuracy
two large studies, each of which contained more
than 400 patients; in these studies, accuracy
was lower (i.e., 63.3% and 69%). most
inaccuracy results from over staging of T2
lesions
 EUS cannot reliably distinguish an irregular
outer rectal wall image as being due to
peritumoral inflammation or transmural tumor
extension.
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Marusch F, Koch A, Schmidt U, et al. Routine use of transrectal ultrasound in rectal carcinoma: results
of a prospective multicenter study. Endoscopy 2002;34: 385^90
CT is other diagnostic modalities . Initial data showed CT T-staging
accuracy of 79% to 94% in patients with primarily advanced Tstage disease
T-staging accuracy fell to 52% to 74% when a broader spectrum
of tumor sizes was analyzed The decrease accuracy for early-stage
lesions confined to the rectal wall. These data suggest that CT Tstage accuracy improves in more locally advanced tumors.
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Nodal staging accuracy has ranged from 54% to 70% (11, 18).
Rifkin MD. Radiology1989;170:319
Goldman S. Gastrointest Radiol 1991;16:259 ^ 63
MRI
MRI
The use of MRI in staging rectal cancer was first
reported in 1986 T-staging accuracy of 59% to
88% was reported
The development of endorectal coils made
detailed imaging of the rectal wall possible, with a
corresponding improvement in T-staging
accuracy of 71% to 91% Comparative studies of
endorectal coil MRI and EUS have shown similar
T-staging
accuracyMaldjian C, Smith R, KilgerA, Schnall M, Ginsberg
G, Kochman M. Endorectal surface coil MR imaging
as a staging technique for rectal carcinoma: a comparison
study to rectal endosonography. Abdom Imaging
2000;25:75^80.
EUS ,reliable ,safe ,no radiation or
contrast
 CT SCAN ,MRI

Aim of the study

The aim of the present study was to
determine the accuracy of EUS for
preoperative staging in patients with rectal
cancer with or without preoperative
chemoradiation.
METHODS
From January 2004 to February 2008, 34 consecutive
patients were referred for local staging of rectal cancer
by EUS.
These patients were stratified into two groups.
Group I 15 paients underwent surgery after EUS
evaluation with prior chemoradiation. Once we had the
results of the histopathological staging (pTN), which was
considered the gold standard, we compared the results
of the previous EUS staging (TN) with those of the pTN
. Group II 34 patients consisted we evaluated accuracy of
CT Scan in staging rectal cancer we used EUS as the
gold standard.
EUS accuracy in rectal cancer staging we
prospectively included all patients
with rectal cancer staged in our unit. We defined
the following as inclusion criteria: tumors
affecting the last 15 cm of the colon ; patients in
whom we could perform a complete EUS staging
examination and who were surgically treated .
We took histological staging as gold-standard for
the analysis of EUS staging results.
Patients were prepared
only with two 250-cc enemas before the
procedure,. No sedation was required in
any patient, and all the explorations were
performed by the same endoscopist with a
radial echoendoscope (pentax)
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Ct Scan of abdomen was reviewed with
our radiologist who was not aware of EUS
or Histopath result
Symptoms
ABDOMINAL PAIN
ANAL PAIN
BLEEDING /RECTUM
DIARRHEA
CONSTIPATION
ALTERD BOWEL HABBIT
ANOREXIA
ANEMIA
WT LOSS
40%
28%
94%
31%
40%
22%
31%
18%
54%
EUS Gender
33%
67%
male
female
EUS Smoking%
3%
13%
34%
50%
smoking
no smok
na
shesha
alchol EUS
3%
41%
56%
alchol
no alchol
NA
PR mass EUS
40%
60%
palp.PR mass
no palp PR mass
EUS chemotherapy
26%
74%
chemotherapy
no chemotherapy
Results
34 patients with rectal cancer during the
mentioned period. Of these 12(36%)women
and 22 (64%)men. Mean age was 54.7 ±
(range: 21-87).
Family HX of colon cancer 4 (11%) patients
The accuracy of Eus vs surgical
pathologically defined T-stage (15
patients)
 12 out of 15 patients were accurately
staged (80%)
 2/15 were overstaged (13%) and
 1/15 were understaged (7%)
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The accuracy of EUS vs surgical
pathology in N staging
13/15 were accurately staged (87%)
 2/15 were overstaged (13%)
 0/15 were understaged (0%)
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The accuracy of CT vs surgical
pathologically defined T-stage (15
patients)
 7/16 were accurately staged (44%)
 6/16 were overstaged (38%)
 3/16 were understaged (19%)
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The accuracy of CT vs surgical
pathology in N staging
 9/16 were accurately staged (56%)
 5/16 were overstaged (31%)
 2/16 were understaged (12.5%)
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Accurately
staged
Overstaged
understaged
(80%)
(13%)
(7%)
(87%)
(13%)
(0%)
ECT Scan T stage (44%)
(38%)
(19%)
CT Scan N stage
(31%)
(12.5%)
EUS
EUS
T satge
N stage
(56%)
CT pelvis diagnostic accuracy of T
staging when compared to EUS (34)
 20/34 were accurately staged (58%)
 6/34 were overstaged
(17%)
 8/34 were understaged
(23%)

CT pelvis diagnostic accuracy of N
staging when compared to EUS
 20/34 were accurately N staged (58%)
 10/34 were overstaged
(29%)
 4/34 were understaged
(11%)
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Accurately
staged
Overstaged
understaged
CT Scan T
staging
(58%)
(17%)
(23%)
CT Scan N
staging
(58%)
(29%)
(11%)
In conclusion, we can affirm that, according
to our data, EUS offers high accuracy for
rectal cancer staging, with a good
correlation with histological staging
regarding T stage ,it is more safe
,noninvasive .
in our experience, the diagnostic accuracy of
EUS for T and N staging of rectal cancer is
80% and 87% respectively, similar results
as previously published for T staging for
rectal cancer.
But N staging was higher than published
data
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In our study the EUS was more accurate
than the Ct scan in staging rectal cancer
Thank you