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Staging of rectal cancer by EUS:
depth of infiltration in T3 cancers is important
Christian Jürgensen, MD, Andreas Teubner, MD,
Jörg-Olaf Habeck, MD, Friederike Diener, MD,
Hans Scherübl, MD, Ulrich Stölzel, MD
Gastrointest Endosc 2011;73:325-8
R4 조경민/ prof.이창균
Background
Rectal carcinoma :
risk of recurrence
Modern treatment
concepts:
based on preoperative
tumor staging
EUS or MRI
Recurrence-free survival rate :P=0.02
Minimal invasive
• N=42
• minimally invasive T3
Advanced rectal cancer
(invasion < 2 mm beyond MRI by EUS)
& advanced T3 disease
(invasion > 2 mm)
J Gastroenterol Hepatol 2004;19:750-5
Endosonographic differentiation of superficial & deep infiltration in T3 stage
prognostic relevance
Locally advanced tumors
(T3, T4)
Therefore
Discrimination
indication
between T1/2 and T3/4 cancers
for neoadjuvant therapy
is crucial for treatment strategies
lymph node involvement
Z Gastroenterol 2004;42:1129-77
ObjectiveDetermine the accuracy of preoperative staging by endorectal
US with a focus on endosonographic T3 stage (uT3)
PATIENTS AND METHODS
Community and tertiary referral hospital
was performed from 1996 to 2004, when uT3 cancers were
not considered for neoadjuvant therapy
Part retrospective, part prospective study.
PATIENTS AND METHODS
Inclusion criteria
• Between 1996 and 2004 (not
considered for neoadjuvant
therapy)
Exclusion criteria
• Incomplete staging by
endorectal US before surgical
resection.
• 83 consecutive patients with de
novo rectal carcinoma
(confirmed by preoperativehistology)
Data on sex, age, preoperative treatment, and postoperative histology :
obtained from patients’ medical records.
METHODS
retrospectively by evaluation
of paper prints and reports.
Maximum depth of tumor infiltration
uT1 : Mucosa (first echo-poor layer in EUS) and/or
submucosa (following echo-rich layer)
uT2 : Muscularis propria (second echo-poor layer) but not beyond
uT3 : Beyond the muscularis propria
Minimally invasive uT3: Infiltration up to 2 mm
Advanced uT3: infiltration deeper than 2 mm
uT4 : Infiltration of adjacent structures and/or peritoneum
RESULTS
RESULTS
Results of T staging assessed by endosonography (uT)
versus postoperative pathology (pT)
Inaccurate staging
between T2 and T3
stages
Representing
14 of 20
(70%) with
incorrect T staging
RESULTS
A substantial proportion of pT2 cancers :
overstaged as uT3 cancer by transrectal US
 EUS overstaging of patients with pT2 was significantly more frequent
in minimally invasive uT3 compared with advanced UT3
(8 of 16 & 1 of 24
P =0 .001)invasive uT3 rectal cancer:
minimally
higher risk of overstaging of pT2 cancer
Discrimination between T1/2 and T3/4
cancers is crucial for treatment
 minimally invasive uT3 cancer :
the accuracy of the crucial discrimination between T1/2 and T3/4 : 50%
 the accuracy of discrimination between T1/2 and T3/4 by EUS
; 88% in this cohort
RESULTS
N staging assessed by endosonography (uN0/2) versus
pathology (pN0/2)
Accuracy of
endosonographic
N staging
: 57% (45 of 78)
RESULTS
Lymph node involvement assessed by
endosonography (uN0/) versus pathology (pN0/)
whether lymph nodes
involved (N) or
not (N0)
increasing to
63% (49 of 78)
CONCLUSIONS
Locally advanced tumors
(T3, T4)
The high probability of overstaging may be a reason
to refer patients with minimally invasive uT3N0
by EUS for surgery without neoadjuvant
therapy
indication
for neoadjuvant therapy
lymph node involvement