直肠MRI与直肠超声预测直肠癌新辅助治疗后完全缓解临床价值研究
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摘要
目的评价直肠MRI和直肠超声检查对直肠癌新辅助治疗后完全缓解的临床诊断价值。方法自2014年5月开始前瞻性登记北京协和医院确诊中低位直肠腺癌并接受新辅助放化疗的病人的临床病理数据,提取截止至2018年6月登记病人的相关资料。病人均于新辅助治疗前及新辅助治疗结束后6～7周接受直肠MRI或直肠超声两种检查手段评估肿瘤分期,评估后2周内接受根治性手术。将术后病人石蜡病理学分期与术前分期进行对比,计算直肠MRI、直肠超声及两种检查手段联合使用对诊断完全缓解的灵敏度、特异度、准确率及约登指数,并通过ROC曲线评价直肠MRI及直肠超声的临床诊断价值。结果共入组247例病人,212例病人具备新辅助放化疗前后直肠MRI结果,直肠MRI诊断ypT0N0的灵敏度、特异度、准确率及约登指数分别为15.9%、94.0%、77.8%及0.1;163例病人具备直肠超声评估结果,其灵敏度、特异度、准确率及约登指数分别为23.1%、94.9%、83.4%及0.2;同时具备两次直肠MRI及直肠超声结果的128例病人中,联合诊断的灵敏度、特异度、准确率及约登指数分别为13.6%、98.1%、83.6%及0.1。直肠MRI及直肠超声诊断ypT0N0的ROC曲线下面积为0.656及0.742,两者应用于相同受试者ROC曲线下面积分别为0.517和0.667。结论直肠超声和直肠MRI诊断直肠癌新辅助治疗后完全缓解的特异度较高而灵敏度极低。对于任一检查评估为非完全缓解的病人,仍应建议积极行根治性手术;对于其评估为完全缓解的病人,仍有可能存在肿瘤细胞残余,此时应结合肛门指诊、乙状结肠镜检查,在医患共同决策下谨慎施行"观察等待"治疗策略。
Objective To offer some important insights into clinical decision-making by evaluating endorectal ultrasound and rectal MRI when they were used to predict pathological complete response for rectal cancer patients who were performed neoadjuvant therapy. Methods The study was a prospective cohort study which was conducted at a single tertiary care center. Patients diagnosed with mid-low rectal cancer between May 2014 and June 2018 in Peking Union Medical College Hospital were collected in the study. Both of their endorectal ultrasound and rectal MRI were performed to evaluate the tumor stage before their preoperative chemoradiation and were reevaluated at the 6 to 7 th weeks after their preoperative radiation treatment. The pathological preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity,specificity,accuracy and Youden index of each evaluation method and their combination were calculated. The ROC curve was administered likewise. Results A total of 247 patients were enrolled in the study. The sensitivity,specificity,accuracy,positive predictive value,negative predictive value and Youden index for ypT0 N0 separate evaluation of for whom was qualified as compete endorectal ultrasound(163 patients) and of rectal MRI(212 patients) was15.9% and 23.1%,94.0% and 94.9%,77.8% and 83.4%,0.1 and 0.2. Combined two methods,the data were recorded as 13.6%,98.1%,83.6% and 0.1.Area under curve ROC for ultrasound and MRI when using specifically for ypT0 N0 measurement was 0.656 and 0.742.The two modalities showed 0.517 and 0.667 in terms of AUC when comparing with each other. Conclusion The sensitivity of MRI and ERUS as terms of diagnosing complete response is rather unsatisfactory,although they all bear a relatively good specificity. For the patients not diagnosed with clinical response by one of the two methods,radical operations were strongly recommended. For the patients confirmed as complete response by both modalities,there still exists possibilities that residual tumor persists,"watch and wait"approach can be taken cautiously and the patient must be followed up intensely.
Objective To offer some important insights into clinical decision-making by evaluating endorectal ultrasound and rectal MRI when they were used to predict pathological complete response for rectal cancer patients who were performed neoadjuvant therapy. Methods The study was a prospective cohort study which was conducted at a single tertiary care center. Patients diagnosed with mid-low rectal cancer between May 2014 and June 2018 in Peking Union Medical College Hospital were collected in the study. Both of their endorectal ultrasound and rectal MRI were performed to evaluate the tumor stage before their preoperative chemoradiation and were reevaluated at the 6 to 7 th weeks after their preoperative radiation treatment. The pathological preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity,specificity,accuracy and Youden index of each evaluation method and their combination were calculated. The ROC curve was administered likewise. Results A total of 247 patients were enrolled in the study. The sensitivity,specificity,accuracy,positive predictive value,negative predictive value and Youden index for ypT0 N0 separate evaluation of for whom was qualified as compete endorectal ultrasound(163 patients) and of rectal MRI(212 patients) was15.9% and 23.1%,94.0% and 94.9%,77.8% and 83.4%,0.1 and 0.2. Combined two methods,the data were recorded as 13.6%,98.1%,83.6% and 0.1.Area under curve ROC for ultrasound and MRI when using specifically for ypT0 N0 measurement was 0.656 and 0.742.The two modalities showed 0.517 and 0.667 in terms of AUC when comparing with each other. Conclusion The sensitivity of MRI and ERUS as terms of diagnosing complete response is rather unsatisfactory,although they all bear a relatively good specificity. For the patients not diagnosed with clinical response by one of the two methods,radical operations were strongly recommended. For the patients confirmed as complete response by both modalities,there still exists possibilities that residual tumor persists,"watch and wait"approach can be taken cautiously and the patient must be followed up intensely.
引文
[1]Pasetto LM,Pucciarelli S,Agostini M,et al.Neoadjuvant treatment for locally advanced rectal carcinoma[J].Crit Rev Oncol Hematol,2004,52(1):61-71.
[2]Glimelius B,P?hlman L,Cervantes A,et al.Rectal cancer:ES-MO Clinical Practice Guidelines for diagnosis,treatment and follow-up[J].Ann Oncol,2010,21(suppl 5):v82-86.
[3]Habr-Gama A,Perez RO,Wynn G,et al.Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer:characterization of clinical and endoscopic findings for standardization[J].Dis Colon Rectum,2010,53(12):1692-1698.
[4]Smith JJ,Chow OS,Eaton A,et al.Organ preservation in patients with rectal cancer with clinical complete response after neoadjuvant therapy[J].J Clin Oncol,2015,33:509.
[5]武爱文,王林,杜长征,等.中低位直肠癌新辅助治疗后等待观察或器官保留手术的单中心35例报告[J].中华胃肠外科杂志,2017,20(4):417-424.
[6]Guillem JG,Chessin DB,Shia J,et al.Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point[J].J Clin Oncol,2005,23(15):3475-3479.
[7]Liu S,Zhong GX,Zhou WX,et al.Can endorectal ultrasound,MRI,and mucosa integrity accurately predict the complete response for mid-low rectal cancer after preoperative chemoradiation?A prospective observational study from a single medical center[J].Dis Colon Rectum,2018,61(8):903.
[8]de Jong EA,ten Berge JC,Dwarkasing RS,et al.The accuracy of MRI,endorectal ultrasonography,and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy:A metaanalysis[J].Surgery,2016,159(3):688-699.
[9]Kye BH,Kim HJ,Kim G,et al.Multimodal assessments are needed for restaging after neoadjunvant chemoradiation therapy in rectal cancer patients[J].Cancer Res Treat,2016,48(2):561-566.
[10]Curvo-Semedo L,Lambregts DM,Maas M,et al.Rectal cancer:assessment of complete response to preoperative combined radiation therapy with chemotherapy--conventional MR volumetry versus diffusion-weighted MR imaging[J].Radiology,2011,260(3):734-743.
[11]Rengo M,Picchia S,Marzi S,et al.Magnetic resonance tumor regression grade(MR-TRG)to assess pathological complete response following neoadjuvant radiochemotherapy in locally advanced rectal cancer[J].Oncotarget,2017,8(70):114746-114755.
[12]Liu Z,Zhang XY,Shi YJ,et al.Radiomics analysis for evaluation of pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer[J].Clin Cancer Res,2017,23(23):7253-7262.
[13]Zhao RS,Wang H,Zhou ZY,et al.Restaging of locally advanced rectal cancer with magnetic resonance imaging and endoluminal ultrasound after preoperative chemoradiotherapy:a systemic review and meta-analysis[J].Dis Colon Rectum,2014,57(3):388-395.
[14]Perez RO,Pereira DD,Proscurshim I,et al.Lymph node size in rectal cancer following neoadjuvant chemoradiation--can we rely on radiologic nodal staging after chemoradiation?[J].Dis Colon Rectum,2009,52(7):1278.
[15]Memon S,Lynch AC,Bressel M,et al.Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy[J].Colorectal Dis,2015,17(8):748.
[16]Zhao YL,Cao DM,Zhou QC,et al.Accuracy of endorectal endoscopic ultrasound(EUS)for locally advanced rectal cancer(LARC)restaging after neoadjuvant chemoradiotherapy(NAT):A Meta-analysis[J].Hepatogastroenterology,2014,61(132):978-983.
[17]Maas Monique,Beets-Tan Regina GH,Lambregts Doenja MJ,et al.Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer[J].J Clin Oncol,2011,29(35):4633-4640.
[18]Martens Milou H,Maas Monique,Heijnen Luc A,et al.Longterm outcome of an organ preservation program after neoadjuvant treatment for rectal cancer[J].J Natl Cancer Inst,2016,108(12):171.
[2]Glimelius B,P?hlman L,Cervantes A,et al.Rectal cancer:ES-MO Clinical Practice Guidelines for diagnosis,treatment and follow-up[J].Ann Oncol,2010,21(suppl 5):v82-86.
[3]Habr-Gama A,Perez RO,Wynn G,et al.Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer:characterization of clinical and endoscopic findings for standardization[J].Dis Colon Rectum,2010,53(12):1692-1698.
[4]Smith JJ,Chow OS,Eaton A,et al.Organ preservation in patients with rectal cancer with clinical complete response after neoadjuvant therapy[J].J Clin Oncol,2015,33:509.
[5]武爱文,王林,杜长征,等.中低位直肠癌新辅助治疗后等待观察或器官保留手术的单中心35例报告[J].中华胃肠外科杂志,2017,20(4):417-424.
[6]Guillem JG,Chessin DB,Shia J,et al.Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point[J].J Clin Oncol,2005,23(15):3475-3479.
[7]Liu S,Zhong GX,Zhou WX,et al.Can endorectal ultrasound,MRI,and mucosa integrity accurately predict the complete response for mid-low rectal cancer after preoperative chemoradiation?A prospective observational study from a single medical center[J].Dis Colon Rectum,2018,61(8):903.
[8]de Jong EA,ten Berge JC,Dwarkasing RS,et al.The accuracy of MRI,endorectal ultrasonography,and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy:A metaanalysis[J].Surgery,2016,159(3):688-699.
[9]Kye BH,Kim HJ,Kim G,et al.Multimodal assessments are needed for restaging after neoadjunvant chemoradiation therapy in rectal cancer patients[J].Cancer Res Treat,2016,48(2):561-566.
[10]Curvo-Semedo L,Lambregts DM,Maas M,et al.Rectal cancer:assessment of complete response to preoperative combined radiation therapy with chemotherapy--conventional MR volumetry versus diffusion-weighted MR imaging[J].Radiology,2011,260(3):734-743.
[11]Rengo M,Picchia S,Marzi S,et al.Magnetic resonance tumor regression grade(MR-TRG)to assess pathological complete response following neoadjuvant radiochemotherapy in locally advanced rectal cancer[J].Oncotarget,2017,8(70):114746-114755.
[12]Liu Z,Zhang XY,Shi YJ,et al.Radiomics analysis for evaluation of pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer[J].Clin Cancer Res,2017,23(23):7253-7262.
[13]Zhao RS,Wang H,Zhou ZY,et al.Restaging of locally advanced rectal cancer with magnetic resonance imaging and endoluminal ultrasound after preoperative chemoradiotherapy:a systemic review and meta-analysis[J].Dis Colon Rectum,2014,57(3):388-395.
[14]Perez RO,Pereira DD,Proscurshim I,et al.Lymph node size in rectal cancer following neoadjuvant chemoradiation--can we rely on radiologic nodal staging after chemoradiation?[J].Dis Colon Rectum,2009,52(7):1278.
[15]Memon S,Lynch AC,Bressel M,et al.Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy[J].Colorectal Dis,2015,17(8):748.
[16]Zhao YL,Cao DM,Zhou QC,et al.Accuracy of endorectal endoscopic ultrasound(EUS)for locally advanced rectal cancer(LARC)restaging after neoadjuvant chemoradiotherapy(NAT):A Meta-analysis[J].Hepatogastroenterology,2014,61(132):978-983.
[17]Maas Monique,Beets-Tan Regina GH,Lambregts Doenja MJ,et al.Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer[J].J Clin Oncol,2011,29(35):4633-4640.
[18]Martens Milou H,Maas Monique,Heijnen Luc A,et al.Longterm outcome of an organ preservation program after neoadjuvant treatment for rectal cancer[J].J Natl Cancer Inst,2016,108(12):171.