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GASTROINTESTINAL IMAGING
MRCP, FRCR
and D MURRAY,
MRCP, FRCR
doi: 10.1259/imaging.
20110078
2013 The British Institute of
Radiology
Cite this article as: Steward MJ, Murray D. Staging of colorectal cancer. Imaging 2013;22:20110078.
imaging.birjournals.org
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Classifications according to American Joint Committee for Cancer staging manual, 7th edition [4].
vessel (arrow) illustrating extramural venous invasion adjacent to a stenosing splenic flexure colonic tumour.
identifiable on MDCT include smooth or nodular extension of a discrete mass of tumour tissue beyond the
contour of the bowel wall with extension into pericolic
fat. Use of coronal or sagittal imaging can improve detection of this extramural invasion for more accurate
staging.
T4 lesions include tumours that penetrate the surface of
the visceral peritoneum, directly invade or are adherent
to other organs or structures, or tumours where there is
evidence of perforation. The identification of peritoneal
infiltration has been used to classify patients as high risk
by recent groups [5, 6].
MDCT has limited accuracy for the detection of nodal
stage, largely because of its inability to detect micrometastases. The criterion of a nodal mass larger than 1 cm
in diameter or a group of three or more nodes is used for
positivity. Accuracy rates are still poor and range from
60% to 80%. Some advocate the use of enhancement
characteristics and suggest an enhancement greater than
100 HU, representing malignancy [6, 7].
Extramural venous invasion as an independent prognostic factor has been evaluated by MDCT, and classified
[6, 7]. The appearances of nodular spread into small vessels or definite enhancing tumour spread along a large
vein are considered to define positivity. The accuracy of
these observations is currently an area of active research.
MDCT pre-operatively can alter management by
demonstrating T4 invasion that will modify the surgical
approach. In addition it may identify a complication related to the primary tumour. Examples include intestinal
obstruction, pericolic abscess, intussusception (Figure 3)
and acute appendicitis. Local tumour perforation through
the peritoneal membrane carries an unfavourable prognosis, and risks dissemination of malignant cells via
transcoelomic spread and peritoneal involvement.
After curative resection patients with colorectal cancer
should also have regular surveillance. Current guidance
suggests a minimum of two MDCTs of the chest,
MRI technique
Figure 3. Coronal multidetector CT demonstrating an ascending colon tumour with intussusception (arrow) as a complication
causing obstruction.
imaging.birjournals.org
TR sagittal (ms)
TR axial (ms)
TE sagittal (ms)
TE axial (ms)
Slices sagittal
Slices axial
Echo-train length
Field of view (mm)
Acquisitions sagittal
Acquisitions axial
Phase-encoding
5080
4018
132
80
23
20
23
250
3
2
Anteroposterior
5362
100
16
16
160
6
Inferosuperior
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sidewall lymph nodes, and whether they have any suspicious features, should be noted.
With the use of total mesorectal excision for complete
surgical excision of the primary tumour, the circumferential resection margin (CRM) needs to be identified
during interpretation (Figure 10). The CRM is formed by
the mesorectal fascia, which envelops the mesorectum
and constitutes the dissection plane in total mesorectal
excision. The MR images need to be obtained in a plane
perpendicular to the rectum and mesorectum, and these
oblique axial images will then correspond precisely with
the specimen resected [19].
Measurements are taken of the distance from the tumour to the mesorectal fascia, the potential CRM. If the
tumour lies within 1 mm of the mesorectal fascia, then
this is a potentially positive margin (Figure 11) [20]. The
risk of local recurrence can also be stratified according to
the characteristics of rectal tumours predicted by MRI
(Table 3).
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The staging of low rectal tumours will involve assessment of the sphincter complex, and the ability to achieve
clear radial and distal margins is key to success. For these
low rectal tumours at or below the puborectalis sling, it
should be noted whether there is full-thickness invasion
of muscularis propria, invasion into the intersphincteric
plane or external sphincter [21]. If this is present extralevator abdominoperineal excision is indicated instead of
low anterior resection. Pelvic exenteration is reserved for
invasion beyond the external sphincter into ischiorectal
tissue.
High
Medium
Low
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Conclusions
Advances in colorectal tumour staging are now established beyond just the detection of metastases. The use of
MDCT and MRI are central to multidisciplinary meetings
to plan treatment strategy and assess tumour response to
these treatments.
References
1. Office for National Statistics. Cancer Statistics registrations:
registrations of cancer diagnosed in England. London, UK:
Office for National Statistics; 2009.
2. National Institute for Health and Clinical Excellence. Diagnosis and management of colorectal cancer. London, UK:
National Institute for Health and Clinical Excellence; 2011.
3. Dighe S, Swift I, Brown G. CT staging of colon cancer. Clin
Rad 2008;63:13729.
4. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL,
Trotti A. AJCC cancer staging manual. 7th edition. New
York, NY: Springer; 2010.
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