Clinical and Experimental Medicine

, Volume 19, Issue 2, pp 225–234 | Cite as

The value of four imaging modalities in diagnosing lymph node involvement in rectal cancer: an overview and adjusted indirect comparison

  • Ya Gao
  • Jipin Li
  • Xueni Ma
  • Jiancheng Wang
  • Bo Wang
  • Jinhui TianEmail author
  • Gen ChenEmail author
Original Article


Several systematic reviews have investigated the accuracy of imaging modalities for lymph node involvement of rectal cancer, but there are considerable differences in conclusions. This overview aimed to assess the methodological and reporting quality of systematic reviews that evaluated the diagnostic value of imaging modalities for lymph node involvement in patients with rectal cancer and to compare the diagnostic value of different modalities for lymph node involvement. The PubMed, EMBASE, Cochrane Library and Chinese Biomedicine Literature were searched to identify relevant systematic reviews. The methodological quality was assessed using the AMSTAR checklist, and the reporting quality was assessed using PRISMA-DTA checklist. The indirect comparison was conducted to compare the accuracy of different imaging modalities. Seven systematic reviews involving 353 primary studies were included. The median (Range) AMSTAR scores were 6.0 (4.0–9.0); the median (Range) PRISMA-DTA scores were 18.0 (11.0–23.0). Sensitivity of MRI [0.69 (95% CI 0.63, 0.77)] was significantly higher than that of ERUS [0.57 (95% CI 0.53, 0.62)]. Specificity of ERUS [0.80 (95% CI 0.77, 0.83)] was significantly higher than that of CT [0.72 (95% CI 0.67, 0.78)]. Positive likelihood ratio of EUS [3.04 (95% CI 2.75, 3.36)] was significantly higher than that of CT [2.21 (95% CI 1.69, 2.90)]. EUS had better diagnostic value than CT and ERUS in the diagnosis of lymph node involvement. Compared with CT and ERUS, MRI was more sensitive. EUS and MRI had comparable diagnostic accuracy, but no modality was proved to be particularly accurate.


Rectal cancer Lymph node involvement Imaging modality Diagnostic accuracy Overview 



Systematic review


Endoscopic ultrasound


Computed tomography


Magnetic resonance imaging


Endorectal ultrasonography






Diagnostic odds ratio


Positive likelihood ratio


Negative likelihood ratio


Confidence interval


Assessment of multiple systematic reviews


Preferred reporting items for systematic reviews and meta-analysis diagnostic test accuracy


Author contributions

YG, JT, and GC planned and designed the study. YG and JL screened potential studies and extracted data from the included studies. XM, JW, and BW assessed the risk of bias and summarized the evidence. YG and JT performed the statistical analysis. YG and GC wrote the first draft. JT and GC revised the draft. All authors approved the final version of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that there is no conflict of interest.

Ethical approval

Ethical approval and patient consent are not required since this is an overview based on published studies.

Informed consent

All analyses were based on previously published studies; thus, no informed consent is required.

Supplementary material

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Supplementary material 1 (DOCX 19 kb)
10238_2019_552_MOESM2_ESM.xlsx (13 kb)
Supplementary material 2 (XLSX 13 kb)
10238_2019_552_MOESM3_ESM.xlsx (11 kb)
Supplementary material 3 (XLSX 11 kb)
10238_2019_552_MOESM4_ESM.xlsx (11 kb)
Supplementary material 4 (XLSX 11 kb)


  1. 1.
    Maier A, Fuchsjäger M. Preoperative staging of rectal cancer. Eur J Radiol. 2003;47:89–97.CrossRefGoogle Scholar
  2. 2.
    Foti PV, Privitera G, Piana S, et al. Locally advanced rectal cancer: qualitative and quantitative evaluation of diffusion-weighted MR imaging in the response assessment after neoadjuvant chemo-radiotherapy. Eur J Radiol Open. 2016;3:145–52.CrossRefGoogle Scholar
  3. 3.
    Jhaveri KS, Hosseini-Nik H. MRI of rectal cancer: an overview and update on recent advances. AJR Am J Roentgenol. 2015;205:W42–55.CrossRefGoogle Scholar
  4. 4.
    Kang H, O’Connell JB, Leonardi MJ, Maggard MA, McGory ML, Ko CY. Rare tumors of the colon and rectum: a national review. Int J Colorectal Dis. 2007;22:183–9.CrossRefGoogle Scholar
  5. 5.
    Salerno G, Sinnatamby C, Branagan G, Daniels IR, Heald RJ, Moran BJ. Defining the rectum: surgically, radiologically and anatomically. Colorectal Dis. 2006;8(Suppl 3):5–9.CrossRefGoogle Scholar
  6. 6.
    Heo SH, Kim JW, Shin SS, Jeong YY, Kang HK. Multimodal imaging evaluation in staging of rectal cancer. World J Gastroenterol. 2014;20:4244–55.CrossRefGoogle Scholar
  7. 7.
    Siegel R, Naishadham D, Jemal A. Cancer statistics. CA Cancer J Clin. 2013;63:11–30.CrossRefGoogle Scholar
  8. 8.
    Puli SR, Reddy JB, Bechtold ML, Choudhary A, Antillon MR, Brugge WR. Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review. Ann Surg Oncol. 2009;16:1255–65.CrossRefGoogle Scholar
  9. 9.
    Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992;326:658–62.CrossRefGoogle Scholar
  10. 10.
    Larsson SC, Orsini N, Wolk A. Diabetes mellitus and risk of colorectal cancer: a meta-analysis. J Natl Cancer Inst. 2005;97:1679–87.CrossRefGoogle Scholar
  11. 11.
    Cho E, Smith-Warner SA, Ritz J, et al. Alcohol intake and colorectal cancer: a pooled analysis of 8 cohort studies. Ann Intern Med. 2004;140:603–13.CrossRefGoogle Scholar
  12. 12.
    Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk for colon cancer and adenoma in men. Ann Intern Med. 1995;122:327–34.CrossRefGoogle Scholar
  13. 13.
    Paskett ED, Reeves KW, Rohan TE, et al. Association between cigarette smoking and colorectal cancer in the Women’s Health Initiative. J Nat Cancer Inst. 2007;99:1729–35.CrossRefGoogle Scholar
  14. 14.
    Franklin JM, Anderson EM, Gleeson FV. MRI features of the complete histopathological response of locally advanced rectal cancer to neoadjuvant chemoradiotherapy. Clin Radiol. 2012;67:546–52.CrossRefGoogle Scholar
  15. 15.
    Del Vescovo R, Trodella LE, Sansoni I, et al. MR imaging of rectal cancer before and after chemoradiation therapy. Radiol Med. 2012;117:1125–38.CrossRefGoogle Scholar
  16. 16.
    Arbea L, Díaz-González JA, Subtil JC, et al. Patterns of response after preoperative intensity-modulated radiation therapy and capecitabine/oxaliplatin in rectal cancer: is there still a place for ecoendoscopic ultrasound. Int J Radiat Oncol Biol Phys. 2011;81:439–44.CrossRefGoogle Scholar
  17. 17.
    de Jong EA, ten Berge JC, Dwarkasing RS, Rijkers AP, van Eijck CH. The accuracy of MRI, endorectal ultrasonography, and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy: a metaanalysis. Surgery. 2016;159:688–99.CrossRefGoogle Scholar
  18. 18.
    Gunderson LL, Jessup JM, Sargent DJ, Greene FL, Stewart A. Revised tumor and node categorization for rectal cancer based on surveillance, epidemiology, and end results and rectal pooled analysis outcomes. J Clin Oncol. 2010;28:256–63.CrossRefGoogle Scholar
  19. 19.
    Benson AB 3rd, Bekaii-Saab T, Chan E, et al. Rectal cancer. J Natl Compr Canc Netw. 2012;10:1528–64.CrossRefGoogle Scholar
  20. 20.
    Xing D, Wang B, Zhang W, et al. Intra-articular platelet-rich plasma injections for knee osteoarthritis: an overview of systematic reviews and risk of bias considerations. Int J Rheum Dis. 2017;20:1612–30.CrossRefGoogle Scholar
  21. 21.
    Tian J, Zhang J, Ge L, Yang K, Song F. The methodological and reporting quality of systematic reviews from China and the USA are similar. J Clin Epidemiol. 2017;85:50–8.CrossRefGoogle Scholar
  22. 22.
    McInnes MDF, Moher D, Thombs BD, et al. Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA statement. JAMA. 2018;319:388–96.CrossRefGoogle Scholar
  23. 23.
    Willis BH, Quigley M. The assessment of the quality of reporting of meta-analyses in diagnostic research: a systematic review. BMC Med Res Methodol. 2011;11:163.CrossRefGoogle Scholar
  24. 24.
    Ge L, Wang JC, Li JL, et al. The assessment of the quality of reporting of systematic reviews/meta-analyses in diagnostic tests published by authors in China. PLoS ONE. 2014;9:e85908.CrossRefGoogle Scholar
  25. 25.
    Engstrom PF, Arnoletti JP, Benson AB 3rd, et al. NCCN clinical practice guidelines in oncology: rectal cancer. J Natl Compr Canc Netw. 2009;7:838–81.CrossRefGoogle Scholar
  26. 26.
    Li XT, Sun YS, Tang L, Cao K, Zhang XY. Evaluating local lymph node metastasis with magnetic resonance imaging, endoluminal ultrasound and computed tomography in rectal cancer: a meta-analysis. Colorectal Dis. 2015;17:O129–35.CrossRefGoogle Scholar
  27. 27.
    Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging–a meta-analysis. Radiology. 2004;232:773–83.CrossRefGoogle Scholar
  28. 28.
    Zhao RS, Wang H, Zhou ZY, Zhou Q, Mulholland MW. Restaging of locally advanced rectal cancer with magnetic resonance imaging and endoluminal ultrasound after preoperative chemoradiotherapy: a systemic review and meta-analysis. Dis Colon Rectum. 2014;57:388–95.CrossRefGoogle Scholar
  29. 29.
    Squires JE, Sullivan K, Eccles MP, Worswick J, Grimshaw JM. Are multifaceted interventions more effective than single-component interventions in changing health-care professionals’ behaviours? An overview of systematic reviews. Implement Sci. 2014;9:152.CrossRefGoogle Scholar
  30. 30.
    Ge L, Tian JH, Li XX, et al. Epidemiology characteristics, methodological assessment and reporting of statistical analysis of network meta-analyses in the field of cancer. Sci Rep. 2016;6:37208.CrossRefGoogle Scholar
  31. 31.
    Jaspers MW, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc. 2011;18:327–34.CrossRefGoogle Scholar
  32. 32.
    Monasta L, Batty GD, Cattaneo A, et al. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes Rev. 2010;11:695–708.CrossRefGoogle Scholar
  33. 33.
    Li JL, Ge L, Ma JC, et al. Quality of reporting of systematic reviews published in “evidence-based”. Chin J Syst Rev. 2014;3:58.CrossRefGoogle Scholar
  34. 34.
    Al-Sukhni E, Milot L, Fruitman M, et al. Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and circumferential resection margin involvement in patients with rectal cancer: a systematic review and meta-analysis. Ann Surg Oncol. 2012;19:2212–23.CrossRefGoogle Scholar
  35. 35.
    Zhou Y, Shao W, Lu W. Diagnostic value of endorectal ultrasonography for rectal carcinoma: a meta-analysis. J Cancer Res Ther. 2014;10(Suppl):319–22.CrossRefGoogle Scholar
  36. 36.
    Fung-Kee-Fung SD. Therapeutic approaches in the management of locally advanced rectal cancer. J Gastrointest Oncol. 2014;5:353–61.Google Scholar
  37. 37.
    Guo J, Liu Z, Sun S, et al. Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors. Endosc Ultrasound. 2013;2:125–33.CrossRefGoogle Scholar
  38. 38.
    Hsieh PS, Changchien CR, Chen JS, et al. Comparing results of preoperative staging of rectal tumor using endorectal ultrasonography and histopathology. Chang Gung Med J. 2003;26:474–8.Google Scholar
  39. 39.
    Kulig J, Richter P, Gurda-Duda A, Gach T, Klek S. The role and value of endorectal ultrasonography in diagnosing T1 rectal tumors. Ultrasound Med Biol. 2006;32:469–72.CrossRefGoogle Scholar
  40. 40.
    Lin S, Luo G, Gao X, et al. Application of endoscopic sonography in preoperative staging of rectal cancer: six-year experience. J Ultrasound Med. 2011;30:1051–7.CrossRefGoogle Scholar
  41. 41.
    Dewhurst C, Rosen MP, Blake MA, et al. ACR Appropriateness Criteria pretreatment staging of colorectal cancer. J Am Coll Radiol. 2012;9:775–81.CrossRefGoogle Scholar
  42. 42.
    Samee A, Selvasekar CR. Current trends in staging rectal cancer. World J Gastroenterol. 2011;17:828–34.CrossRefGoogle Scholar
  43. 43.
    Kwok H, Bissett IP, Hill GL. Preoperative staging of rectal cancer. Int J Colorectal Dis. 2000;15:9–20.CrossRefGoogle Scholar
  44. 44.
    Li H, Yao L, Jin P, et al. MRI and PET/CT for evaluation of the pathological response to neoadjuvant chemotherapy in breast cancer: a systematic review and meta-analysis. Breast. 2018;40:106–15.CrossRefGoogle Scholar
  45. 45.
    Devillé WL, Buntinx F, Bouter LM, et al. Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol. 2002;2:9.CrossRefGoogle Scholar
  46. 46.
    Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. BMJ. 2003;326:41–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Evidence-Based Medicine Centre, School of Basic Medical SciencesLanzhou UniversityLanzhou CityChina
  2. 2.Pathogens Biology Institute, School of Basic Medical SciencesLanzhou UniversityLanzhou CityChina
  3. 3.The Second Clinical Medical College of Lanzhou UniversityLanzhouChina
  4. 4.Gansu Provincial HospitalLanzhouChina
  5. 5.Department of NursingRehabilitation Center Hospital of Gansu ProvinceLanzhouChina
  6. 6.Key Laboratory of Evidence-Based Medicine and Knowledge Translation of Gansu ProvinceLanzhouChina
  7. 7.Basic Medical SchoolGuilin Medical UniversityGuangxiChina

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