Abstract
INTRODUCTION: Transrectal ultrasound is the standard method for preoperative staging of rectal cancer. This study reviews the accuracy of transrectal ultrasound staging for T3 disease and its use in the selection of patients for neoadjuvant chemoradiation. METHODS: One hundred seventeen patients underwent preoperative transrectal ultrasound evaluation for rectal cancer. Accuracy of transrectal ultrasound was evaluated among 70 patients not receiving preoperative chemoradiation. Forty-seven patients received neoadjuvant chemoradiation based on transrectal ultrasound results. Tumor downstaging and early recurrence were evaluated among 45 of 47 patients receiving neoadjuvant chemoradiation. RESULTS: Among 70 nonirradiated patients, 19 were pathologic Stage pT3. Transrectal ultrasound correctly identified 18 of 19 patients with Stage pT3 (sensitivity, 94.7 percent). Transrectal ultrasound correctly identified 44 of 51 patients with less than pT3 disease (specificity, 86.3 percent). After preoperative chemoradiation in 45 patients with ultrasound Stage uT3 or uT4 tumors, 56 percent of them experienced a reduction in T stage. Residual nodal disease was found in 31 percent of patients. A complete pathologic response with no residual disease at operation was observed in 22 percent of patients. During a median follow-up period of 21 months after diagnosis, seven patients experienced a recurrence of their disease at a median of 12 months after diagnosis. Five of seven patients with recurrence were among a subgroup of ten patients who both failed to downstage T and had residual nodal disease at operation. CONCLUSION: Transrectal ultrasound is an accurate modality for selecting patients for neoadjuvant treatment. Preoperative chemoradiation produced downstaging in 56 percent of patients. Factors related to early recurrence included residual nodal disease and failure to downstage T after neoadjuvant chemoradiation.
Similar content being viewed by others
References
Cancer Facts and Figures 1998. Atlanta: American Cancer Society, 1998.
Hyams DM, Mamounas EP, Petrelli N,et al. A clinical trial to evaluate the worth of preoperative multimodality therapy in patients with operable carcinoma of the rectum: a progress report of National Surgical Breast and Bowel Project Protocol R-03. Dis Colon Rectum 1997;40:131–9.
Cedermark B, Johansson H, Rutqvist LE, Wilking N. The Stockholm I trial of preoperative short term radiotherapy in operable rectal carcinoma. A prospective randomized trial. Stockholm Colorectal Cancer Study Group. Cancer 1995;75:2269–75.
SEER Cancer Statistics Review, 1973–1995. Bethesda, MD: National Cancer Institute, 1998.
NIH consensus conference. Adjuvant therapy for patients with colon and rectal cancer. JAMA 1990;264:1444–50.
Meade PG, Blatchford GJ, Thorson AG, Christensen MA, Ternent CA. Preoperative chemoradiation downstages locally advanced ultrasound-staged rectal cancer. Am J Surg 1995;170:609–12.
Berger C, de Mureta A, Garaud P,et al. Preoperative radiotherapy (RT) for rectal cancer: predictive factors of tumor downstaging and residual tumor cell density (RTCD): prognostic implications. Int J Radiat Oncol Biol Phys 1997;37:619–27.
Grann A, Minsky BD, Cohen AM,et al. Preliminary results of preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for clinically resectable T3 rectal cancer. Dis Colon Rectum 1997;40:515–22.
Kim NK, Senagore AJ, Luchtefeld MA, MacKeigan JM, Mazier WP, Belknap K. Adjuvant radiation therapy in resectable rectal cancer: should local recurrence rates affect the decision? Am Surg 1997;63:579–84.
Minsky B, Cohen A, Enker W,et al. Preoperative 5-fluorouracil, low-dose leucovorin, and concurrent radiation therapy for rectal cancer. Cancer 1994;73:273–80.
Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial [published erratum appears in N Engl J Med 1997;336:1539]. N Engl J Med 1997;336:980–7.
Randomised trial of surgery aloneversus radiotherapy followed by surgery for potentially operable locally advanced rectal cancer. Medical Research Council Rectal Cancer Working Party. Lancet 1996;348:1605–10.
Beynon J, Foy DM, Roe AM, Temple LN, Mortensen NJ. Endoluminal ultrasound in the assessment of local invasion in rectal cancer. Br J Surg 1986;73:474–7.
Cavaliere F, Pemberton JH, Cosimelli M, Fazio VW, Beart RW Jr. Coloanal anastomosis for rectal cancer: long-term results at the Mayo and Cleveland Clinics. Dis Colon Rectum 1995;38:807–12.
MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993;341:457–60.
Rich T, Gunderson LL, Lew R, Galdibini JJ, Cohen AM, Donaldson G. Patterns of recurrence of rectal cancer after potentially curative surgery. Cancer 1983;52:1317–29.
Mendenhall WM, Million RR, Pfaff WW. Patterns of recurrence in adenocarcinoma of the rectum and rectosigmoid treated with surgery alone: implications in treatment planning with adjuvant radiation radiation therapy. Int J Radiat Oncol Biol Phys 1983;9:977–85.
Walz BJ, Green MR, Lindstrom ER, Butcher HR. Anatomical prognostic factors after abdominoperineal resection. Int J Radiat Oncol Biol Phys 1981;7:477–84.
Malcolm AW, Perencevich NP, Olson RM, Hanley JA, Chaffey JT, Wilson RE. Analysis of recurrence patterns following curative resection for carcinoma of the colon and rectum. Surg Gynecol Obstet 1981;152:131–6.
Veazey PR, McBride CM. Pelvic recurrence of cancer after abdominoperineal resection of the rectum. South Med J 1979;72:1545–7,1553.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of laterau tumour spread and surgical excision. Lancet 1986;2:996–9.
Pilipshen SJ, Heilweil M, Quan SH, Sternberg SS, Enker WE. Patterns of pelvic recurrence following definitive resections of rectal cancer. Cancer 1984;53:1354–62.
Abulafi AM, Williams NS. Local recurrence of colorectal cancer: the problem, mechanisms, management and adjuvant therapy. Br J Surg 1994;81:7–19.
Prolongation of the disease-free interval in surgically treated rectal carcinoma. Gastrointestinal Tumor Study Group. N Engl J Med 1985;312:1465–72.
Mendenhall WM, Bland KI, Copeland EM,et al. Does preoperative radiation therapy enhance the probability of local control and survival in high-risk distal rectal cancer? Ann Surg 1992;215:696–705.
Hoth DF, Petrucci PE. Natural history and staging of colon cancer. Semin Oncol 1976;3:331–6.
Marsh PJ, James RD, Schofield PF. Adjuvant preoperative radiotherapy for locally advanced rectal carcinoma: results of a prospective, randomized trial. Dis Colon Rectum 1994;37:1205–14.
Gerard A, Buyse M, Nordlinger B,et al. Preoperative radiotherapy as adjuvant treatment in rectal cancer. Final results of a randomized study of the European Organization for Research and Treatment of Cancer (EORTC). Ann Surg 1988;208:606–14.
Goldberg PA, Nicholls RJ, Porter NH, Love S, Grimsey JE. Long-term results of a randomised trial of shortcourse low-dose adjuvant pre-operative radiotherapy for rectal cancer: reduction in local treatment failure. Eur J Cancer 1994;30A:1602–6.
Balslev I, Pedersen M, Teglbjaerg PS,et al. Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid. A randomized multicenter study. Cancer 1986;58:22–8.
Fisher B, Wolmark N, Rockette H,et al. Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01. J Natl Cancer Inst 1988;80:21–9.
Mameghan H, Gray BN, de Zwart J,et al. Adjuvant post-operative radiotherapy in rectal cancer: results from the ANZ Bowel Cancer Trial (Protocol 8202). Australas Radiol 1991;35:61–5.
Treurniet DA, van Putten WL, Wereldsma JC,et al. Postoperative radiation therapy for rectal cancer. An interim analysis of a prospective, randomized multicenter trial in The Netherlands. Cancer 1991;67:2042–8.
Påhlman L, Glimelius B. Pre- or postoperative radiotherapy in rectal and rectosigmoid carcinoma. Report from a randomized multicenter trial. Ann Surg 1990;211:187–95.
Marks G, Mohiuddin M, Goldstein SD. Sphincter preservation for cancer of the distal rectum using high dose preoperative radiation. Int J Radiat Oncol Biol Phys 1988;15:1065–8.
Berard P, Papillon J. Role of pre-operative irradiation for anal preservation in cancer of the low rectum. World J Surg 1992;16:502–9.
Roberson SH, Heron HC, Kerman HD, Bloom TS. Is anterior resection of the rectosigmoid safe after preoperative radiation? Dis Colon Rectum 1985;28:254–9.
Friedmann P, Garb JL, McCabe DP,et al. Intestinal anastomosis after preoperative radiation therapy for carcinoma of the rectum. Surg Gynecol Obstet 1987;164:257–60.
Minsky BD, Cohen AM, Kemeny N,et al. Enhancement of radiation-induced downstaging of rectal cancer by fluorouracil and high-dose leucovorin chemotherapy. J Clin Oncol 1992;10:79–84.
Boulis WS, Gerard A, Loygue J, Camelot D, Buyse M, Duez N. Final results of a randomized trial on the treatment of rectal cancer with preoperative radiotherapy alone or in combination with 5-fluorouracil, followed by radical surgery. Trial of the European Organization on Research and Treatment of Cancer Gastrointestinal Tract Cancer Cooperative Group. Cancer 1984;53:1811–8.
Landry JC, Koretz MJ, Wood WC,et al. Preoperative irradiation and fluorouracil chemotherapy for locally advanced rectosigmoid carcinoma: phase I-II study. Radiology 1993;188:423–6.
Chen ET, Mohiuddin M, Brodovsky H, Fishbein G, Marks G. Downstaging of advanced rectal cancer following combined preoperative chemotherapy and high dose radiation. Int J Radiat Oncol Biol Phys 1994;30:169–75.
Nicholls RJ, Mason AY, Morson BC, Dixon AK, Fry IK. The clinical staging of rectal cancer. Br J Surg 1982;69:404–9.
Fleshman JW, Myerson RJ, Fry RD, Kodner IJ. Accuracy of transrectal ultrasound in predicting pathologic stage of rectal cancer before and after preoperative radiation therapy. Dis Colon Rectum 1992;35:823–9.
Herzog U, von Flüe M, Tondelli P, Schuppisser JP. How accurate is endorectal ultrasound in the preoperative staging of rectal cancer? Dis Colon Rectum 1993;36:127–34.
Lupo L, Angelelli G, Pannarale O, Altomare D, Macarini L, Memeo V. Improved accuracy of computed tomography in local staging of rectal cancer using water enema. Int J Colorectal Dis 1996;11:60–4.
Netri G, Coco C, Valentini V,et al. Clinical staging of rectal cancer. Results of a prospective continuing study. Ital J Surg Sci 1985;15:169–74.
Hildebrandt U, Feifel G. Preoperative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum 1985;28:42–6.
Solomon MJ, McLeod RS. Endoluminal transrectal ultrasonography: accuracy, reliability, and validity. Dis Colon Rectum 1993;36:200–5.
Napoleon B, Pujol B, Berger F, Valette PJ, Gerard JP, Souquet JC. Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy. Br J Surg 1991;78:785–8.
Katsura Y, Yamada K, Ishizawa T, Yoshinaka H, Shimazu H. Endorectal ultrasonography for the assessment of wall invasion and lymph node metastasis in rectal cancer. Dis Colon Rectum 1992;35:362–8.
Durdey P, Williams NS. Pre-operative evaluation of patients with low rectal carcinoma. World J Surg 1992;16:430–6.
Orrom WJ, Wong WD, Rothenberger DA, Jensen LL, Goldberg SM. Endorectal ultrasound in the preoperative staging of rectal tumors: a learning experience. Dis Colon Rectum 1990;33:654–9.
Meyenberger C, Huch BR, Bertschinger P, Zala GF, Klotz HP, Krestin GP. Endoscopic ultrasound and endorectal magnetic resonance imaging: a prospective, comparative study for preoperative staging and follow-up of rectal cancer. Endoscopy 1995;27:469–79.
Starck M, Bohe M, Fork FT, Lindstrom C, Sjoberg S. Endoluminal ultrasound and low-field magnetic resonance imaging are superior to clinical examination in the preoperative staging of rectal cancer. Eur J Surg 1995;161:841–5.
Thaler W, Watzka S, Martin F,et al. Preoperative staging of rectal cancer by endoluminal ultrasoundversus magnetic resonance imaging: preliminary results of a prospective, comparative study. Dis Colon Rectum 1994;37:1189–93.
Waizer A, Powsner E, Russo I,et al. Prospective comparative study of magnetic resonance imagingversus transrectal ultrasound for preoperative staging and follow-up of rectal cancer: preliminary report. Dis Colon Rectum 1991;34:1068–72.
Holdsworth PJ, Johnston D, Chalmers AG,et al. Endoluminal ultrasound and computed tomography in the staging of rectal cancer. Br J Surg 1988;75:1019–22.
Salo JO, Mecklin JP, Jarvinen H, Lehtonen T. Endoultrasonography for preoperative staging of rectal cancer. Ann Chir Gynaecol 1988;77:57–60.
Beynon J, Roe AM, Foy DM, Channer JL, Virjee J, Mortensen NJ. Preoperative staging of local invasion in rectal cancer using endoluminal ultrasound. J R Soc Med 1987;80:23–4.
Beynon J, Mortensen NJ, Foy DM, Channer JL, Virjee J, Goddard P. Endorectal sonography: laboratory and clinical experience in Bristol. Int J Colorectal Dis 1986;1:212–5.
Author information
Authors and Affiliations
About this article
Cite this article
Adams, D.R., Blatchford, G.J., Lin, K.M. et al. Use of preoperative ultrasound staging for treatment of rectal cancer. Dis Colon Rectum 42, 159–166 (1999). https://doi.org/10.1007/BF02237121
Issue Date:
DOI: https://doi.org/10.1007/BF02237121