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Value of Endorectal Utrasound for Staging Rectal Cancer Following Neoadjuvant Chemoradiation Therapy
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摘要:
目的 评估直肠腔内超声(endorectal ultrasound, ERUS)对直肠癌术前新辅助放化疗后分期的应用价值。 方法 回顾性分析2011年9月至2012年9月北京协和医院收治的直肠癌患者62例, 所有患者在放化疗前后完成ERUS检查并分期, 最终经直肠全系膜切除术(total mesorectal excision, TME)切除肿瘤, 并进行病理分期, 比较ERUS分期与手术病理分期结果。 结果 62例患者中8例放化疗后肿瘤消失, 达到病理完全缓解(pT0N0), 但ERUS均未准确诊断; 30例对放化疗反应较好的患者中仅7例肿瘤浸润深度超声分期(uT分期)准确。ERUS的uT总准确性仅40.3%(25例), 过高分期58.1%(36例), 过低分期1.6%(1例)。ERUS诊断转移淋巴结的敏感性、特异性、阳性预测值、阴性预测值分别为60.0%、84.6%、42.9%、91.7%。 结论 ERUS对直肠癌放化疗后肿瘤浸润深度超声分期(uT分期), 尤其是对放化疗反应较好的肿瘤分期准确性偏低, 且无法诊断肿瘤完全病理缓解。ERUS对淋巴结转移诊断的特异性和阴性预测值较高, 可对直肠癌预后作出很好的预判。 Abstract:Objective To assess the value of endorectal ultrasound (ERUS) for staging rectal cancer after neoadjuvant chemoradiation. Methods We retrospectively analyed the clinical data of 62 patients with rectal cancer between September 2011 and September 2012 in our hospital. ERUS was performed before and after chemoradiation therapy in all patients. All patients underwent subsequent total mesorectal excision (TEM) and completed pathologic staging. The results of ERUS were compared with the postoperatively pathologic staging. Results After chemoradiation, 8 patients had no residual disease at pathologic staging(pT0N0)which was not correctly predicted by ERUS. Of 30 patients who responded well to the chemoradiation therapy, only 7 achieved correct ultrasonic staging (uT). The overall accuracy of ERUS for uT was only 40.3%(25/62), while 36 patients (58.1%)were overstaged and 1 patient (1.6%)was understaged. The sensitivity, specificity, and positive and negative predictive values for nodal staging were 60.0%, 84.6%, 42.9%, 91.7%, respectively. Conclusions The ERUS uT of rectal cancer after chemoradiation is inaccurate, especially in patients with evidence of response. Meanwhile, ERUS cannot reliably predict tumor pathological complete remission. However, ERUS has high specificity and negative predictive value for nodal staging and therefore is valuable in predicting the prognosis. -
图 1 患者女，48岁，术后病理示直肠中-高分化腺癌，侵透肠壁全层达外周脂肪，两断端未见癌；淋巴结转移癌，病理分期：pT3N1
A.新辅助放化疗前ERUS分期: uT3N1；B.新辅助放化疗后ERUS分期: uT3N1，ERUS示肿瘤病灶内部仍为均匀低回声，仅病灶形态大小略有变化，肠壁层次未见恢复
图 2 患者男，50岁，术后病理示直肠溃疡区黏膜大部缺失，肌层内见中分化腺癌浸润，侵透肌层，并见大片状坏死，钙化灶及泡沫状细胞，淋巴结未见转移癌，病理分期：pT3N0
A.新辅助放化疗前ERUS分期: uT3N0；B.新辅助放化疗后ERUS分期: uT3N0，ERUS示肿瘤病灶内部回声增强及强回声，肠壁层次未见恢复
图 3 患者男，50岁，术后病理示直肠肠壁肌层可见小灶低分化癌残余，累及深肌层，淋巴结未见转移癌，病理分期：pT2N0
A.新辅助放化疗前ERUS分期: uT3N0；B.新辅助放化疗后ERUS分期: uT3N0，ERUS示肿瘤病灶处肠壁层次部分恢复，黏膜及黏膜下层中强回声恢复完整，固有肌层低回声稍厚，浆膜层仍可见不规则低回声突起
表 1 直肠腔内超声分期与病理分期比较
超声分期 病理分期(n) 总计
(n)超声分期[n(%)] pT0 pT1 pT2 pT3 pT4 过低分期 过高分期 准确分期 uT0 0 1 0 0 0 1 1(100) 0 0 uT1 0 0 0 0 0 0 0 0 0 uT2 1 0 6 0 0 7 0 1(14.3) 6(85.7) uT3 8 4 22 19 0 53 0 34(64.2) 19(35.8) uT4 0 0 0 1 0 1 0 1(100) 0 总计 9 5 28 20 0 62 1(1.6) 36(58.1) 25(40.3) 
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表 2 直肠腔内超声淋巴结转移分期与病理淋巴结转移分期比较
超声分期 病理分期(n) 总计
(n)超声分期准确性[n(%)] pN0 pN1 过低分期 过高分期 准确分期 uN0 44 4 48 4(8.3) 0 44(91.7) uN1 8 6 14 0 8(57.1) 6(42.9) 总计 52 10 62 4(6.5) 8(12.9) 50(80.6)
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