Accuracy of EUS in Accuracy of EUS in diagnosis of rectal diagnosis of rectal

cancer KKUH experience cancer KKUH experience

A.Aljebreen ,A.Aljebreen ,N. AzzamN. Azzam , S. , S. Sharqawi,A.Alzubaidi,T.Alturiki Sharqawi,A.Alzubaidi,T.Alturiki

Colorectal cancer is the most common Colorectal cancer is the most common gastrontestinal malignancy and the gastrontestinal malignancy and the second cause of cancer-related second cause of cancer-related deaths in West countriesdeaths in West countries

. Colorectal cancer represents an . Colorectal cancer represents an important health problem in western important health problem in western countries, with an increasing countries, with an increasing incidence in our areaincidence in our area

over the last few years.over the last few years.

The prognosis of rectal cancer is related The prognosis of rectal cancer is related to several factors, such asto several factors, such as

depth of tumoral invasion, number of depth of tumoral invasion, number of metastatic lymph nodes, involvement metastatic lymph nodes, involvement of circumferential margin of circumferential margin

Preoperative staging is of great Preoperative staging is of great importance for adequate importance for adequate management.management.

Recent data have shown that preoperativeradiation 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 inresectable rectal cancer. Swedish Rectal Cancer Trial.

NEngl JMed 1997;336:980^7.

EUS CT SCAN MRI with endorectal coil

EUSEUS

Several studies have shown a high Several studies have shown a high accuracy rate of endoscopic accuracy rate of endoscopic ultrasound (EUS) in the preoperative ultrasound (EUS) in the preoperative staging of rectal cancer.staging of rectal cancer.

These studies reported an overall These studies reported an overall accuracy of 83% (75−90%) for T accuracy of 83% (75−90%) for T stage and 75% (65−80%) for N stage.stage and 75% (65−80%) for N stage.

Bartram C. Gastroenterol Clin North Am 2002; 31: 827-39. Fusaroli P. Eur J Gastroenterol Hepatol 2005; 17: 293-301.

EUS Accuracy EUS Accuracy

two large studies, each of which contained two large studies, each of which contained more than 400 patients; in these studies, more than 400 patients; in these studies, accuracy was lower (i.e., 63.3% and 69%). accuracy was lower (i.e., 63.3% and 69%). most inaccuracy results from over staging most inaccuracy results from over staging of of T2 lesionsT2 lesions

EUS cannot reliably distinguish an irregular outer rectal wall image as being due to peritumoral inflammation or transmural tumor extension.

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-CT is other diagnostic modalities . Initial data showed CT T-staging accuracy of 79% to 94% in patients with primarily staging accuracy of 79% to 94% in patients with primarily advanced T-stage diseaseadvanced T-stage disease

T-staging accuracy fell to 52% to 74% when a broader T-staging accuracy fell to 52% to 74% when a broader spectrumspectrum

of tumor sizes was analyzed The decrease accuracy for early-of tumor sizes was analyzed The decrease accuracy for early-stage lesions confined to the rectal wall. These data suggest stage lesions confined to the rectal wall. These data suggest that CT T-stage accuracy improves in more locally advanced that CT T-stage accuracy improves in more locally advanced tumors. tumors.

Nodal staging accuracy has ranged from 54% to 70% (11, Nodal staging accuracy has ranged from 54% to 70% (11, 18).18).

Rifkin MD. Radiology1989;170:319Goldman S. Gastrointest Radiol 1991;16:259 ^ 63

MRIMRI

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 madedetailed 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, GinsbergG, Kochman M. Endorectal surface coil MR imaging

as a staging technique for rectal carcinoma: a comparisonstudy to rectal endosonography. Abdom Imaging

2000;25:75^80.

EUS ,reliable ,safe ,no radiation or contrast

CT SCAN ,MRI

Aim of the study Aim of the study

The aim of the present study was to The aim of the present study was to determine the accuracy of EUS for determine the accuracy of EUS for preoperative staging in patients with preoperative staging in patients with rectal cancer with or without rectal cancer with or without preoperative chemoradiation.preoperative chemoradiation.

METHODSMETHODS

From January 2004 to February 2008,From January 2004 to February 2008, 34 consecutive 34 consecutivepatients were referred for local staging of rectal cancerpatients were referred for local staging of rectal cancerby EUS. by EUS. These patients were stratified into two groups.These patients were stratified into two groups.Group IGroup I 15 paients underwent surgery after EUS 15 paients underwent surgery after EUS

evaluation with prior chemoradiation. Once we had evaluation with prior chemoradiation. Once we had the results of the histopathological staging (pTN), the results of the histopathological staging (pTN), which was considered the gold standard, we which was considered the gold standard, we compared the results of the previous EUS staging compared the results of the previous EUS staging (TN) with those of the pTN(TN) with those of the pTN

. . Group IIGroup II 34 patients consisted we evaluated 34 patients consisted we evaluated accuracy of CT Scan in staging rectal cancer we accuracy of CT Scan in staging rectal cancer we used EUS as the gold standard. used EUS as the gold standard.

EUS accuracy in rectal cancer staging we EUS accuracy in rectal cancer staging we prospectivelyprospectively included all patients included all patients

with rectal cancer staged in our unit. We with rectal cancer staged in our unit. We defined the following as inclusion criteria: defined the following as inclusion criteria: tumors affecting the last 15 cm of the tumors affecting the last 15 cm of the colon ; patients in whom we could perform colon ; patients in whom we could perform a complete EUS staging examination and a complete EUS staging examination and who were surgically treated . We took who were surgically treated . We took histological staging as gold-standard for histological staging as gold-standard for the analysis of EUS staging results.the analysis of EUS staging results.

Patients were preparedPatients were prepared

only with two 250-cc enemas before only with two 250-cc enemas before the procedure,. No sedation was the procedure,. No sedation was required in any patient, and all the required in any patient, and all the explorations were performed by the explorations were performed by the same endoscopist with a radial same endoscopist with a radial echoendoscope (pentax)echoendoscope (pentax)

Ct Scan of abdomen was reviewed with our radiologist who was not aware of EUS or Histopath result

Symptoms Symptoms

ABDOMINAL PAINABDOMINAL PAIN 40%40%

ANAL PAINANAL PAIN 28%28%

BLEEDING /RECTUMBLEEDING /RECTUM 94%94%

DIARRHEADIARRHEA 31%31%

CONSTIPATIONCONSTIPATION 40%40%

ALTERD BOWEL ALTERD BOWEL HABBITHABBIT

22%22%

ANOREXIAANOREXIA 31%31%

ANEMIAANEMIA 18%18%

WT LOSSWT LOSS 54%54%

EUS Gender

67%

33%

male female

EUS Smoking%

13%

50%

34%

3%

smoking no smok na shesha

alchol EUS

3%

56%

41%

alchol no alchol NA

PR mass EUS

60%

40%

palp.PR mass no palp PR mass

EUS chemotherapy

74%

26%

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 The accuracy of Eus vs surgical pathologically defined T-stage pathologically defined T-stage (15 patients)(15 patients)

12 out of 15 patients were accurately 12 out of 15 patients were accurately staged staged (80%)(80%)

2/15 were overstaged 2/15 were overstaged (13%)(13%) and and 1/15 were understaged 1/15 were understaged (7%)(7%)

The accuracy of EUS vs surgical The accuracy of EUS vs surgical pathology in N stagingpathology in N staging

13/15 were accurately staged 13/15 were accurately staged (87%)(87%) 2/15 were overstaged 2/15 were overstaged (13%)(13%) 0/15 were understaged 0/15 were understaged (0%)(0%)

The accuracy of CT vs surgical The accuracy of CT vs surgical pathologically defined T-stage pathologically defined T-stage (15 patients)(15 patients)

7/16 were accurately staged 7/16 were accurately staged (44%)(44%) 6/16 were overstaged 6/16 were overstaged (38%)(38%) 3/16 were understaged (3/16 were understaged (19%)19%)   

The accuracy of CT vs surgical The accuracy of CT vs surgical pathology in N stagingpathology in N staging

9/16 were accurately staged 9/16 were accurately staged (56%)(56%) 5/16 were overstaged 5/16 were overstaged (31%)(31%) 2/16 were understaged 2/16 were understaged (12.5%)(12.5%)

Accurately staged

Overstaged understaged

EUS T satge (80%) (13%) (7%)

EUS N stage (87%) (13%) (0%)

ECT Scan T stage

(44%) (38%) (19%)

CT Scan N stage

(56%) (31%) (12.5%)

CT pelvis diagnostic accuracy of CT pelvis diagnostic accuracy of T staging when compared to EUS T staging when compared to EUS (34)(34)

20/34 were accurately staged 20/34 were accurately staged (58%)(58%) 6/34 were overstaged 6/34 were overstaged (17%)(17%) 8/34 were understaged 8/34 were understaged (23%)(23%)

CT pelvis diagnostic accuracy of CT pelvis diagnostic accuracy of N staging when compared to EUSN staging when compared to EUS

20/34 were accurately N staged 20/34 were accurately N staged (58%)(58%)

10/34 were overstaged 10/34 were overstaged (29%)(29%)

4/34 were understaged 4/34 were understaged (11%)(11%)

Accurately staged

Overstaged understaged

CT Scan T staging

(58%) (17%) (23%)

CT Scan N staging

(58%) (29%) (11%)

In conclusion, we can affirm that, In conclusion, we can affirm that, according to our data, EUS offers according to our data, EUS offers high accuracy for rectal cancer high accuracy for rectal cancer staging, with a good correlation with staging, with a good correlation with histological staging regarding T stage histological staging regarding T stage ,it is more safe ,noninvasive .,it is more safe ,noninvasive .

in our experience, the diagnostic in our experience, the diagnostic accuracy ofaccuracy of

EUS for T and N staging of rectal cancer EUS for T and N staging of rectal cancer is is 80% and 87% 80% and 87% respectively, similar respectively, similar results as previously published for T results as previously published for T staging for rectal cancer.staging for rectal cancer.

But N staging was higher than But N staging was higher than published data published data

In our study the EUS was more In our study the EUS was more accurate than the Ct scan in staging accurate than the Ct scan in staging rectal cancer rectal cancer

Thank you Thank you