Preoperative local staging of colorectal cancer patients with MDCT.
ABSTRACT To evaluate tumor invasion (T staging) and lymph node metastasis (N staging) of colorectal cancer preoperatively by using multi-detector computerized tomography (MDCT) and to compare with the histopathological findings.
MDCT scan was performed for 73 patients with pathological proven colorectal carcinoma. One radiologist prospectively evaluated the depth of tumor invasion (T staging) and regional lymph node involvement (N staging). The MDCT assessment was then compared with the histopathological findings for accuracy, sensitivity and specificity.
In this study, the best accuracy results had been acquired for T1 and T2 tumors as 90.4% and 73.9%, respectively. For both histopathologically staged N0 and N1 patients, the accuracy results were 61.6%. The distant metastases were not detected in this study.
Our study results showed that the MDCT may be useful in the preoperative assessment for the T and N staging in colorectal carcinoma.
Article: CT colonography with intravenous contrast material: varied appearances of colorectal carcinoma.[show abstract] [hide abstract]
ABSTRACT: Computed tomographic (CT) colonography is a noninvasive, rapidly evolving technique that has been shown in some studies to be comparable with conventional colonoscopy for the screening of colorectal cancer. Because colorectal cancer has a widely varying appearance at both endoscopy and CT colonography, familiarity with the gamut of morphologic appearances can help improve interpretation of the results. The addition of intravenous contrast material to CT colonography can aid differentiation of true colonic masses from pseudolesions such as residual stool and improves the depiction of enhancing masses that might otherwise be obscured by residual colonic fluid. In contrast to staging of most other tumors, staging of colorectal carcinoma depends more on the depth of tumor invasion than on the size of the primary mass. The diverse appearances of colorectal cancers at two- and three-dimensional CT colonography include sessile, annular, ulcerated, necrotic, mucinous, invasive, and noninvasive lesions. Imaging pitfalls that can simulate or obscure neoplasms are retained fecal material or fluid, incomplete distention, and advanced diverticulosis.Radiographics 25(5):1321-34. · 2.85 Impact Factor
Article: Preoperative T and N staging of colorectal cancer: accuracy of contrast-enhanced multi-detector row CT colonography--initial experience.[show abstract] [hide abstract]
ABSTRACT: To evaluate the accuracy of contrast material-enhanced multi-detector row computed tomographic (CT) colonography for preoperative staging of colorectal cancer. Forty-one patients with colorectal carcinoma underwent preoperative contrast-enhanced multi-detector row CT colonography. Images were obtained in the arterial (start delay of 35 seconds) and portal venous (start delay of 70 seconds) phases. The arterial phase was focused on the suspected region of neoplasm, whereas the venous phase included the whole abdomen and pelvis. Two radiologists independently evaluated the depth of tumor invasion into the colorectal wall (T) and regional lymph node involvement (N) on transverse CT images alone and in combination with multiplanar reformations (MPRs). Disagreements were resolved by means of consensus. CT findings were compared with pathologic results, which served as the reference standard. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were assessed. Differences in accuracy for T and N staging were assessed by using the McNemar test. In T staging, overall accuracy was 73% when transverse images were evaluated alone and 83% when they were evaluated in combination with MPRs. This difference was not significant. N staging was associated with an overall accuracy of 59% with transverse images alone and 80% with combined transverse and MPR images (P <.01). Contrast-enhanced multi-detector row CT colonography is an accurate technique for preoperative local staging of colorectal tumors.Radiology 05/2004; 231(1):83-90. · 5.73 Impact Factor
[show abstract] [hide abstract]
ABSTRACT: Whilst imaging of poor prognostic features in rectal cancers has assisted pre-operative treatment stratification, such features have yet to be evaluated in colonic cancers. This study aims to develop criteria for identifying poor prognostic features in colonic tumours and assess the accuracy of CT prediction against histopathology. Criteria were developed for predicting T-stage and N-stage, the presence of extramural vascular invasion and involvement of the retroperitoneal surgical margin (RSM). These criteria were tested on 33 patients with colonic cancer who underwent pre-operative high-resolution CT of their tumour. Two radiologists (Obs 1 and Obs 2) identified independently these poor prognostic features and the results were compared with the final histopathological results. Histological agreement and interobserver variation were calculated using the kappa test. Accuracy of CT prediction of tumour extension beyond muscularis propria was 82% (Obs 1) and 70% (Obs 2). Correct prediction of RSM involvement was 76% (95% confidence interval (CI): 57.8-88.9%) and 79% (95%CI: 61.1-91%) for Obs1 and Obs 2, respectively, with significant agreement between observers (kappa = 0.455, p = 0.050). Prognosis was correctly predicted using CT in 82% (95%CI: 61.5-81.2%) (Obs1) and 85% (95%CI: 68.1-94.9%) (Obs2) with moderate agreement (kappa = 0.459, kappa = 0.527, respectively) with histology. In conclusion, CT has potential as the imaging modality of choice in the pre-operative prediction of poor prognostic features in colonic cancers and could play a role in future treatment stratification.The British journal of radiology 02/2008; 81(961):10-9. · 2.11 Impact Factor
Preoperative Local Staging of Colorectal
Cancer Patients with MDCT
Mustafa Duman1, Sukru Tas1, Eren Ali Mecit1, Erdal Polat1, Ugur Duman2,
Betul Ayca Kurtulus3, Hayrettin Varolgunes1 and Erdal Birol Bostanci1
1Department of Gastrointestinal Surgery and 3Department of Radiology,
Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
2Department of General Surgery, Bursa Sevket Yilmaz Training and Research Hospital, Bursa, Turkey
Corresponding author: Ugur Duman, MD, Bursa Sevket Yilmaz Training and Research Hospital, Department of General
Surgery, Bursa, Turkey; Tel.: +90-224-2955000, Fax: +90-224-2944499; E-mail: email@example.com
Colorectal cancer is the third common malignancy
worldwide and one of the common causes of cancer re-
lated death (1,2). Preoperative evaluation of the extent
of colorectal carcinoma spread indicates the expected
prognosis and also assists management (3). The depth
of bowel wall invasion, presence of lymph node metas-
tases and distant metastases are the major factors that
affect the prognosis of the patient (4). Accurate staging
of colorectal cancer is important to provide the optimal
treatment strategy. Despite preoperative evaluation and
staging of colorectal cancer patient is difficult, comput-
erized tomography (CT) scanning has been very often
used in preoperative staging of colorectal cancer as a
non-invasive instrument with the development of high
resolution scanners, technical refinements in obtaining
better quality as a result. CT is an excellent imaging tool
for screening the distant metastases (5-7). Convention-
al colonoscopy is known to be the gold standard proce-
dure for screening the colon, but does not provide infor-
mation about the depth of the tumor invasion in the wall
of colon, lymph node involvement and distant metasta-
ses (8-10). Advances in CT technologies have increased
interest in the potential role of multi-detector comput-
erized tomography (MDCT) for detection and staging of
colorectal cancer (11). CT is the basic imaging method
of choice for the preoperative staging colorectal carcino-
mas at our clinic. For this instance, the aim of this study
is to determine the accuracy of standard protocol MDCT
in the evaluation of local tumor (T) staging and regional
lymph node (N) status in colorectal carcinomas.
This study had been approved by local ethics commit-
tee of human studies and we got written informed con-
sent from all patients included in the study.
Between August 2007 and November 2010, seventy-
three consecutive patients (34 men with an age range
of 30-79 years and mean age of 61.7 years; 39 women
with an age range of 35-83 years and mean age of 54.38
years) with biopsy proved colorectal carcinoma were
prospectively included in this study. Among the 73 pa-
tients who had a prior colonoscopy, 24 had incomplete
application due to inability to pass a distal stricture. All
patients were operated within two weeks after CT ex-
An MDCT (Toshiba Aquilion 64™, Toshiba Medical
Systems Corp., Tokyo, Japan) scanner was used for this
study. All patients were fasted for at least 10 hours be-
fore MDCT scan and given oral colon cleaning prepara-
tion 12 hours prior to MDCT examination. Oral and in-
travenous contrasts were used in all patients. One thou-
sand milliliters of 3% diluted contrast agent solution
was given orally 60 minutes before imaging. 120mL in-
travenous non-ionic contrast agent (Ultravist®, 370mg
iodine/mL; Schering, Berlin, Germany) was adminis-
tered slowly (3mL/sec.) during the MDCT examination.
Contrast material is contraindicated in patients who
were not included in study. CT acquisitions were per-
formed in the arterial phase (start-delay of 25 seconds)
and in the venous phase (start-delay of 70 seconds). A
section of 0.5mm width was performed. MDCT exami-
nation included from the domes of the diaphragm to the
symphysis pubis. Rectal contrast material or air insuffla-
tions were not the process of CT in patients.
One radiologist who had 6 years of experience in ab-
dominal CT evaluated the images on the workstation by
using soft tissue window settings before surgery in a
blind fashion to colonoscopy results. For the location of
each lesion, the large intestine was divided into eight an-
atomic segments: caecum, ascending colon, hepatic flex-
ure, transverse colon, splenic flexure, descending colon,
Background/Aims: To evaluate tumor invasion (T
staging) and lymph node metastasis (N staging) of
colorectal cancer preoperatively by using multi-de-
tector computerized tomography (MDCT) and to com-
pare with the histopathological findings. Methodolo-
gy: MDCT scan was performed for 73 patients with
pathological proven colorectal carcinoma. One radiol-
ogist prospectively evaluated the depth of tumor inva-
sion (T staging) and regional lymph node involvement
(N staging). The MDCT assessment was then compared
with the histopathological findings for accuracy, sen-
sitivity and specificity. Results: In this study, the best
accuracy results had been acquired for T1 and T2 tu-
mors as 90.4% and 73.9%, respectively. For both histo-
pathologically staged N0 and N1 patients, the accuracy
results were 61.6%. The distant metastases were not
detected in this study. Conclusions: Our study results
showed that the MDCT may be useful in the preoper-
ative assessment for the T and N staging in colorectal
Hepato-Gastroenterology 2012; 59:1108-1112 doi 10.5754/hge11869
© H.G.E. Update Medical Publishing S.A., Athens
Hepato-Gastroenterology 59 (2012)Preoperative Staging of Colorectal Cancer
sigmoid colon and rectum. All patients with colorectal
carcinoma were staged on MDCT according to the mod-
ified TN classification. Modified CT criteria were adapt-
ed from Burton et al. (5) and Hennedige et al. (6). The
reader identified the location of the cancer, extent of
local invasion, lymph node spread and adjacent organ
involvement (Tables 1 and 2). The MDCT staging cri-
teria had been used for local tumor spread and lymph
node involvement (5,6). The radiological assessment
was then compared with the surgical and histopatho-
logical findings. Pathological staging was performed ac-
cording to the tumor, node, metastasis (TNM) classifica-
tion described by the American Joint Committee on Can-
cer (AJCC) for colorectal carcinoma (11). Tomographic T
and N staging data were recorded prospectively in pa-
tients and accuracies were evaluated for postoperative
histopathological T and N staging. Abdominal wall and
spread to adjacent organs were evaluated in operation.
Stage values of T and N were evaluated according to the
localization of the tumor in colon.
Sensitivity, specificity, accuracy were calculated for T
and N staging from MDCT image results. Differences in
accuracy for N and T staging and also differences in ac-
curacy for the locations of T and N staging were assessed
by χ2 and related-samples marginal homogenity tests.
SPSS 19.0 was used for statistical tests and statistical
significance was identified at a confidence level of 5%.
Seventy three patients were enrolled in the study (39
females and 34 males). According to localization, 21 tu-
mors were localized in the right colon ((caecum (n=10),
ascending colon (n=5), hepatic flexure (n=2) and trans-
verse colon (n=4)), 32 tumors were localized in the left
colon (splenic flexure (n=5), descending colon (n=2),
sigmoid colon (n=25)) and 20 tumors were localized in
At histopathological examination, 1 of 73 (1.6%) tu-
mors was staged as T1, 25 of 73 tumors (34.2%) were
staged as T2, 41 of 73 tumors (56.1%) were staged as
T3 and 6 of 73 tumors (8.2%) were staged as T4. MDCT
correctly staged 1 of 1 patient with T1 (100%). On histo-
pathology, 25 patients were staged as T2. MDCT correct-
ly staged 22 of 25 (88%) patients with T2 disease. Two
patients were understaged and one patient was over-
staged as T3 on MDCT. MDCT correctly staged 22 of 41
(53.6%) with T3. Seventeen patients were understaged
and two patients overstaged on MDCT. There were six
patients with T4 stage on histopathology; MDCT cor-
rectly staged 0 of 6 (0%) patients with T4 stage. Six pa-
tients were understaged as T2 or T3 stage on MDCT.
On histopathological examination, 36 of 73 (49.3%)
cancers were staged as N0, 23 of 73 (31.5%) cancers
were staged as N1, 8 of 73 (10.9%) cancers were staged
as N2 and 6 of 73 (8.2%) cancers were staged as N3. On
histopathology 36 patients were staged N0, MDCT cor-
rectly staged of 22 of 36 (61.1%) patients with N0 stage.
Fourteen patients were overstaged as N1-N2 disease.
MDCT correctly staged 12 of 23 (52.1%) patients with
N1 disease. Nine patients were understaged as N0 dis-
ease and two patients overstaged as N2. MDCT correct-
ly staged 1 of 8 (12.5%) patients with N2 disease. Four
patients were understaged as N0 disease and three pa-
tients were understaged as N1 disease. MDCT correctly
staged 1 of 6 (16.6%) patients with N3 stage. Three pa-
tients were understaged as N1 and two patients were
understaged as N0 stage.
MDCT for the assessment of all phases of the T and N
stages were measured separately for the accuracy, sensi-
tivity, specificity and positive predictive value, negative
predictive value (Table 3).
The distribution of CT and histopathological T stages
which were from the same patients were compared us-
ing χ2 and related samples marginal homogeneity tests.
It was found that there was a statistically significant dif-
ference between CT and histopathological T stages of
the same patients (χ2=30.75, p=0.00 (p<0.05)). T3 and
T4 stages were observed different than expected (Fig-
ure 1). Related samples homogeneity test result was
56.00 (p=0.000 (p<0.05)) and it is shown that T stages
are not distributed homogeneously in CT and histopath-
The distribution of CT and histopathological N stages
from the same patients were compared using χ2 and re-
lated samples marginal homogeneity tests. It was found
that there were no statistically significant differences
between CT and histopathological N stages of the same
patients (χ2=16.51, p=0.057 (p>0.05)) (Figure 2). Relat-
ed samples homogeneity test result was 29.00 (p=0.258
Stage MDCT criteria
Intraluminal projection of a colonic lesion without
any visible distortion of the wall layers.
Asymmetrical thickening projecting intraluminally.
Smooth preservation of muscle coat and clear
adjacent pericolic fat.
Smooth and nodular extension of a discrete mass
and disruption of the muscle coat and extension
into pericolic fat.
Nodular penetration through the peritonealised
areas of the muscle coat. Advancing edge of tumour
penetrating the adjacent organs.
TABLE 1. MDCT staging criteria for tumor staging. Modified
from Hennedige et al. (6) and Burton et al. (5).
No lymph node >0.5cm and no abnormal
1-3 lymph node >0.5cm, or abnormal clustering
of 3 more normal- sized lymph nodes.
3-6 lymph nodes >0.5cm.
More than 6 lymph nodes >0.5cm.
TABLE 2. MDCT staging criteria for nodal staging.
Modified from Hennedige et al. (6), Burton et al. (5)
and Dighe et al. (15).
TABLE 3. MDCT assessment of all phases of the T and N stages.
Hepato-Gastroenterology 59 (2012)
(p>0.05)), and it was shown that N stages were distrib-
uted homogeneously in CT and histopathological find-
Colon tumors were classified according to localiza-
tion in colon segment. T stages were found correctly by
MDCT as follows: for right colon 15 of 21 (71.42%), for
left colon 20 of 32 (62.5%), for rectum 10 of 20 (50%).
N stages were found correctly by MDCT as follows: for
right colon 11 of 21 (52.38%), for left colon 15 of 32
(46.87%) and for rectum 10 of 20 (50%). There was no
significant difference between data for T and N stages
according to localization of the tumors (p>0.05).
Accurate preoperative evaluation of the local staging
of the colorectal cancer is required to predict prognosis
and to select most appropriate management. There is no
guideline clearly stating an optimal strategy for preoper-
ative imaging (11,12). Colonoscopy and barium contrast
radiography are the conventional gold standard methods
for detecting and diagnosing colorectal cancers. Howev-
er, total colonoscopy can not be performed in cases with
obstructing colonic lesions and colonoscopy can evaluate
the entire colon successfully in only 60-90% of patients.
It has been demonstrated that the long-term survival rate
increases when a full colonic examination is performed
before surgery (5,8-10,13). Colonoscopy and barium en-
ema do not permit a precise preoperative prediction of tu-
mor spread into adjacent organs, surrounding tissue and
lymph nodes. CT is widely used for preoperative staging
of colorectal cancer but there is no concensus on its use
CT is nowadays the standard modality for staging
colorectal cancers before curative surgical resection. Re-
cently in rectal cancers, preoperative identification of
poor prognostic factors enables safe administration of
neoadjuvant therapies. Similar to rectal cancers, preop-
erative neoadjuvant strategies colonic cancers will be re-
liant on the staging accuracy of CT (15,16). Preoperative
neoadjuvant therapy can provide down staging of tumors
in patients with high risk of poor prognosis. CT has shown
potential not only as a staging tool but also in predicting
prognosis (17). Therefore, the main objective of this study
was to evaluate the overall diagnostic accuracy of MDCT
in T and N staging of colorectal neoplasms.
Advances in CT technology have raised interest in the
potential role of CT for detecting and staging of colorec-
tal cancers. With the development of MDCT thin section
images, faster scan acquisitions, improved resolution and
multi-planar reconstruction images have shown better
accuracy in T and N staging (4,14,18). MDCT has fewer
motion artefacts due to either voluntary or involuntary
movements than single row CT (19). In this study we pre-
ferred to use MDCT as the diagnostic tool of choice to eval-
In our experience, the best sensitivity and accura-
cy values had been acquired for T1, T2 and T3 stages. T
staging accuracy had been found as 90.4% for T1, 73.97%
for T2 and 69.86% for T3. The sensitivities according to
T stages had been found as 100% for T1, 88% for T2 and
53.6 for T3. According to previous reports the overall ac-
curacy of CT in T staging of colorectal cancer ranges be-
tween 41% and 82%. The wide range of accuracy rates
depends on various CT technologies used to evaluate T
stages (20-23). Accuracy rates for T staging with MDCT
were reported to be improved when axial and multi-
planar reconstruction images were evaluated in combi-
M Duman, S Tas, EA Mecit, et al.
of CT and
T stages. (CT:
in a 56 year
cancer found to
be of T3 stage.
mography in a 72
year old woman.
This rectal can-
cer found to be
of T2 stage. His-
firmed T2 stage.
of CT and
N stages. (CT:
Hepato-Gastroenterology 59 (2012)
nation. Small strands of tumor tissue in pericolic fat on
CT images give clues in differentiating T2 from T3 stage.
These strands indicate tumoral involvement in the peri-
colic fat or serosa. Fibrosis, inflammation or congestive
changes may also result in these strand images (4,18,24).
Peritumoral reaction consisting of fibrosis and inflamma-
tion is an important cause of overstaging (25,26). Even
with the improved spatial resolution of MDCT, it is diffi-
cult to differentiate bowel wall layers as conventional sin-
gle row CT (27).
The sensitivity of CT detection depends mainly on the
size of the colorectal tumor and quality of the CT examina-
tion. Conventional CT has undergone significant changes
with the development of MDCT. The prognosis of colorec-
tal cancer is directly related to extent of colorectal wall in-
vasion, lymph node involvement and distant metastases
(28-31). In this study, analysis of the data makes a sugges-
tion that MDCT may correctly stage two parameters, lo-
cal invasion and lymph node metastasis. Despite the fre-
quent use of CT in preoperative evaluation of disseminat-
ed disease in rectal cancer, the role of the CT in local stag-
ing is limited with reported accuracies ranging from 33%
to 82% for T stage (31-33). In our study, MDCT showed an
accuracy of 75% for T1 stage, 70% for T2 stage and 60%
for T3 stage in the assessment of rectal cancer patients. In
the assessment of colon cancer patients, MDCT showed
an accuracy of 96.2% for T1 stage, 75.4 % for T2 stage
and 73.5% for T3 stage (Figures 3 and 4). No patient was
evaluated as T4 either for rectal cancer or colon cancer by
MDCT. It is reported that CT is not enough to detect mi-
croscopic extratumoral extension into the fat surround-
ing the colon and rectum and this situation results in un-
derstaging. Higher soft tissue contrast resolution makes
magnetic resonance imaging more suitable than CT for
evaluating local extent of disease in the pelvis especially
for rectal cancer patients (34).
Intwo recent meta-analyses of 130 and 78 stud-
ies, the comparison of the staging of the colorectal can-
cer using preoperative CT to histopathological examina-
tion have shown that MDCT has the potential to make a
considerable impact in improving the accuracy of stag-
ing of colorectal cancer. According to these analyses, the
main limitation of CT is the inability to accurately iden-
tify malignant nodes. The most impressive results have
been demonstrated by the studies that have utilized sec-
tions thicknesses of 5mm or less. Also these analyses have
shown that preoperative staging of colorectal cancer us-
ing MDCT is highly accurate and safe. Despite the improve-
ments in CT technology, there is already a wide variation
(22-73%) in accuracy for N staging in preoperative eval-
uation of rectal cancer patients with CT (15,16,31,35). In
our study, MDCT showed an accuracy of 75% for N0 stage,
60% for N1 stage, 85% for N2 stage and 80% N3 stage in
the assessment of rectal cancer patients. MDCT showed
an accuracy of 56.6% for N0 stage, 62.6 for N1 stage, 83.1
% for N2 stage and 98.1% N3 stage in the assessment of
colon cancer patients (Figures 5 and 6). There is a lack
of reliable CT criteria for metastatic lymph nodes. Efforts
have been made to identify CT findings indicating metas-
tasis based on analysis of morphologic features. On the
other hand, these efforts are inaccurate to diagnose nor-
mal sized nodes with microscopic tumor involvement or
enlarged benign reactive nodes. Changing the size crite-
ria towards larger or smaller cut-off values does not solve
the conflict in diagnosis because this is the intrinsic limi-
tation of CT for N staging (34,36).
Mostly in practice, CT is evaluated by a single radiol-
ogist. Therefore one radiologist evaluated the MDCT in
our study and the accuracy rate for staging was within
the range reported by other studies previously. Most er-
rors in this study resulted from inaccurate evaluation of
T4 stage, N2 and N3 stage.
In conclusion, our results suggest that the preoper-
ative staging of colorectal cancer using MDCT has good
accuracy in the prediction of T stage (especially T1, T2
and T3 stage) and good accuracy for N staging. Although
there are internal limitations in detecting microscopic in-
vasions, MDCT is a simple and useful technique for either
detecting macroscopic local invasion or whole colon ex-
amination especially in obstructing lesions. MDCT can
identify synchronous carcinomas and/or coexisting po-
lips (37). Advances in imaging technology will increase
the accuracy and usefulness of CT.
Preoperative Staging of Colorectal Cancer
FIGURE 5. Computerized tomography in a 56 year old woman. Lymph
nodes associated with the ascending colon tumor found to be of N2 stage.
Histopathology confirmed N2 stage.
FIGURE 6. Computerized tomography in a 72 year old woman. Lymph
nodes associated with the rectal cancer found to be of N1 stage. Histopa-
thology confirmed N1 stage.
Hepato-Gastroenterology 59 (2012)M Duman, S Tas, EA Mecit, et al.
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