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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 4  |  Page : 1019-1022

Evaluation of preoperative multidetector row computed tomography in colon malignancy with reference to (Local Staging and Lymph Node Status)

Department of Radiodiagnosis, JLN Medical College, DMIMS (DU), Wardha, Maharashtra, India

Date of Submission01-Oct-2022
Date of Decision07-Oct-2022
Date of Acceptance10-Oct-2022
Date of Web Publication10-Feb-2023

Correspondence Address:
Dr. Bhavik Sunit Unadkat
JLN Medical College, Sawangi (M), Wardha, Maharashtra, India, Department of Radiodiagnosis, JLN Medical College, DMIMS (DU), Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_452_22

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A proper preliminary stage is essential for determining the appropriate therapy approach for each patient. Even though controversial, computed tomography (CT) preoperative staging in colorectal cancer (CRC) may be beneficial for planning surgery and neoadjuvant treatment, especially when local tumor extension onto surrounding structures or metastatic disease is identified. CT technology has advanced significantly since the debut of the multidetector row CT (MDCT) scanner. Due to developments in CT technology, the potential usefulness of CT in the diagnosis and staging of CRC has piqued attention. In recent studies, MDCT using multiplanar reformations imaging has shown promise in identifying the local extent and nodal involvement of CRC. CT scans are useful because they give functional as well as anatomical information. As a result, it is only normal to assume that CT will improve CRC preoperative staging accuracy. The exact identification of distant metastases is the most crucial additional information provided by CT. CT offers a relative advantage over CT in the assessment of patients with CRC in terms of tumor penetration thru the walls, extracurricular expansion, and regional lymph node metastases. Patients with metastatic lesions that are suggestive but not definitive should get a CT scan.

Keywords: Colorectal carcinoma, multidetector row computed tomography, tumor node metastasis staging

How to cite this article:
Unadkat BS, Kashikar SV, Mishra GV, Dhande RP. Evaluation of preoperative multidetector row computed tomography in colon malignancy with reference to (Local Staging and Lymph Node Status). J Datta Meghe Inst Med Sci Univ 2022;17:1019-22

How to cite this URL:
Unadkat BS, Kashikar SV, Mishra GV, Dhande RP. Evaluation of preoperative multidetector row computed tomography in colon malignancy with reference to (Local Staging and Lymph Node Status). J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:1019-22. Available from: http://www.journaldmims.com/text.asp?2022/17/4/1019/369508

  Introduction Top

Colorectal cancer (CRC) seems to be as 4th largest in males and the third highest common cancer in female in the world, with about 1 million cases and over half a million deaths per year.[1],[5],[24]

World Health classifies CRC as a single disease.[2] CRC is probably the third most common frequent cancer in men, behind prostate and lung cancer. Subsequently, breast cancer, CRC, has been 2nd largest reason for mortality and the most frequent cancer among women.[3]

In most publications, there is no difference between CRC staging of the colon or rectum. The clinical use of radiological approaches for rectal cancer staging has been demonstrated, with an emphasis on the usage of multidetector row computed tomography (MDCT) and magnetic resonance imaging (MRI). Most studies are retrospective or only include a limited number of patients. Therefore, data on colon cancer (CC) staging are less accurate. Endoscopic ultrasonography, MRI, and computed tomography (CT) all had remained help to investigate CRC stages. MDCT scans, on the other hand, are frequently considered as one of the most acceptable precise ways to detect general settings of CC. CT can be used to determine the extent of tumor advancement through the colon wall, as well as the tumor's extramural extension (T stage), dissemination to regional lymph nodes (N stage), and distant metastases (M stage). The overall accuracy of intestinal preprocessing, oral and rectal imaging technique distribution, colon oxygen distension, and IV contrast used all have an impact on the quality of MDCT for CC staging. Whenever vascular pictures are mixed, T- and N-stage classification improves.[4]

The new standard for identifying colorectal neoplasia is now conventional colonoscopy (CCS), with biopsy and histological confirmation of the diagnosis.[5] If CRC is diagnosed, accurate preoperative staging is of utmost importance for optimal therapeutic planning. The Tumor Node metastasis (TNM) classification is the worldwide accepted system for the stage of CRC. Standard CS, on either hand, has several drawbacks, such as the incapacity to evaluate the extent of mural infiltration or organs beyond the colon, and the inability to exhibit among the whole colon of approximately 5% of individuals, as well as the reality that this is expensive and unpleasant.[6] On the operating table, the CCS is the excision of the tumor with adequate borders and capillary permeability without residual tumor (R0 resection) with initial anastomosis. In CC patients, extramural invasion (EMI) is a crucial prognosis factor. For identifying EMI in colon tumors, preoperative CT shows a high sensitivity.[7] For people with locally advanced CC (Stages IIII), surgery is the sole curative option, and for those with minimal metastases, surgery is a possibly curative alternative (Stage IV).[8]

Colectomy or endoscopic surgery followed by chemotherapy is recommended for advanced or metastatic, amenable to resection, nonmetastatic CC (T1N0 to T4bN4), and adjuvant chemotherapy and colectomy with/without chemotherapeutics is recommended for most of so many accommodating to resection, metastatic CC (T1N0 to T4bN4) (T1N0 to T4bN4). Proper precolectomy local staging can help choose CC treatment.[9]

Clinical studies in advanced or metastatic CC, including the FOxTROT study in the United Kingdom, the Prodige22-ECKINOXE trial in France, and the NCT01918527 trial in Denmark, Norway, and Sweden, all need correct preoperative T staging. The inclusion criteria for these three studies include elevated T3 and T4 CC.[10]

Preoperative MDCT colonoscopy (CS) is a noninvasive method that can reliably detect locoregional spread, lymph node status, and tumor metastasis, as well as assist in defining the patient's treatment needs. The objective for the above research study is to look at the usefulness of preoperative MDCT in CC staging and lymph node status.

In this review, we reviewed the available literature on the diagnostic accuracy of CT for T, N, and M staging of CC patients after the diagnosis of the primary tumor has been made and determined the value of CT for CC staging in clinical practice. In this study, 24 publications were included, and compared and outcomes were discussed.

  Materials and Methods Top

Research strategy

The literature search in numerous internet databases was undertaken in March 2022 for recognizing the paper obligatory on this narrative appraisal arranged with minimally invasive dentistry. Electronic databases such as PubMed, Scopus, Embase, Cochrane library, and ScienceDirect, as well as a manual search utilizing cross-references and textbooks, were searched using MeSH terms/keywords such as “CC,” “TNM Staging,” “CT Colonography,” and “MDCT.” Articles that fit the study's requirements and were published in English from 2000 to April 2021 were included.

Article selection criteria

The review's papers were chosen based on the criteria for inclusion and exclusion. In order to choose the articles for this evaluation, a quality assessment was performed.

Inclusion principles

  1. Studies on CC, CT Colonography, and MDCT
  2. Experimental Studies, Analytical reports.

Exclusion principles

  1. Animal-based studies.

Narrative reviews on colon cancer

After evaluating titles and abstracts, 109 studies were chosen from the 911 that were found. After the evaluation of titles and abstracts, 69 articles were screened. Hand-searching resulted in the addition of 12 articles. Subsequently, the maximum number of records was found to be 81. Full-text articles assessed for the survey were 24, which met the study's goals and were chosen for the review. As shown in [Figure 1] all the studies included were evaluated for participants, interventions, comparisons, outcomes and the type of study design of individual studies and the review study. While selecting articles and collecting data, observer bias was minimized with the help of fellow researchers and the statistical team.
Figure 1: Flow chart of cases selected

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Preoperative diagnostic tools for colorectal cancer

Optical CS, double contrast barium enema, Ultrasound, CT, circulating tumor cell (CTC), MRI, and positron emission tomography are some of the diagnostic procedures for CRC.[11],[12] CTC has the potential to be a complete test for patients with CRC who are undergoing preoperative evaluation. It is particularly good at detecting large CR lesions,[13],[14],[15] allowing for the studying of the entire colon, uniform situations of obstructive lesions, and the localization of segmented tumors. CTC provides for both locoregional and distant staging of extra-colonic tumor spread simultaneously.

CRC can present as broad-based indications (such as rectal bleeding, bowel alterations, stomach discomfort, or anemia) and an abrupt bowel obstruction. A fecal occult blood test, sigmoidoscopy, CS, or CTC may also identify CRC in asymptomatic persons. A CS and biopsy are performed to make the final diagnosis in all cases.

Role of circulating tumor cell in colorectal cancer

CTC has gained traction as a viable screening method. CTC has been proven in several trials to have a sensitivity of more than or equal to 85% in detecting colorectal neoplasms bigger than 1 cm in diameter. CS remains an observed gold standard intended for distinguishing CR malignancy in symptomatic patients and screening high-risk asymptomatic people.[16]

Because it replaces the restrictions of CS, CTC has been offered as an alternate way of assessing CRC. The occurrence of concurrent malignant tumors (1.5%-9.0%) and polyps in people with CRC is a primary focus of our research. The surgical procedure and adjunctive medications need a comprehensive preliminary assessment of the whole colon and exact staging.[16]

CTCs' main advantages of CRC stayed that one aptitude in estimating the whole colon, finishing a failed CS examination, and providing TNM staging. Chung et al.[16] studied 11 individuals with distant occlusive carcinoma who had CTC. On CTC, only 11 patients had coetaneous abrasion. Other advantages of CTC over standard CS include a faster process, lower patient risk without needing IV anesthesia, and much more precise lesion detection. CTC has a lot of shortcomings, including the need for stool purification, longer viewing and interpretation times, and high radiation dosage.

A cutting-edge CTC examination necessitates correct intestinal groundwork, optimum colonic expansion, and suitable scan methodology. For the person having CRC, CTC should additionally include the injection of IV-iodine distinction media since this agrees with the extra-colonic structure assessment that was necessary for the search for distant metastases.[17]

Additional procedures such as barium enema, CTC, endoscopic tattooing, and perioperative CS can be utilized to precisely localize colonic lesions. Overall reliability by CTC in disease localization was 94.7% in 94 patients with CRC.[18] In 65 patients with CRC, CTC showed a sensitivity and specificity of 100% and 96%, respectively, in detecting the site of colonic masses. Still, CS failed to properly localize the tumor in 24% of instances.[19]

Role of multidetector row computed tomography in colorectal cancer

Compared to solo CT, MDCT offers various advantages, including higher spatially and temporally resolutions, faster data capture, a broader field of view, and equivalent coverage times, all while using significantly thinner section magnification.[20] In CTC, narrower section collimation produces near-isotropic voxels. By minimizing volume averaging and boosting z-axis precision for multiplanar reformations and 3D preview, an isotropic image improves polyp detection rates and Staging system accuracy. The overall accuracy of predictive subgroup identification is enhanced by TNM staging, which is congruent with Dukes' classification. Although additional research into the differences between 16-and 4-MDCT for CTC is needed, 16-MDCT can give considerably higher polyp detection capability, less falsified findings, and more appropriate TNM staging than 4-MDCT.

It has been proven that using MDCT reduces the number of false-positive outcomes. Residual feces, retained fluid, insufficient gastrointestinal distinction, and pulmonary objects are the most common causes of false-positive results.[21] On the other hand, separating leftover feces from the colonic polyp utilizing a combination of virtual CS photographs, transverse pictures, and 3D scans was successful. The transverse image better portrayed internal heterogeneity, while the simulated CS view better depicted exterior morphologic features.

According to Morrin et al.,[22] contrast-enhanced CTC indicates significant accuracy in medium size polyps (diameter, five to Nine mm). Dietary fecal tagging[23] can also be used to remove residual fecal particles from photos digitally. Bisacodyl reduces the number of feces that are left behind and the amount of fluid that is retained. Using supine and prone imaging has significantly reduced retained fluid and collapsed segments. Between the supine and prone postures, there was no statistically significant change in mean total bowel distension.

TNM Staging and CTC CT are being used in clinical settings for malignancy, node, and metastasis (TNM) staging of CC, thanks to the advancement of multidetector Ct imaging and multiplanar rehabilitation software, but distinct findings have been published in the literary works at various times for TNM staging of CC. The ESMO consensus recommendations, the SEOM medical recommendations 2018, and the Chinese Society of Clinical Oncology guidelines 2018 all support precolectomy chest/abdominal/pelvic CT for diagnosing and managing CC. CTC can detect CRC in asymptomatic patients, making it an extra screening option.[9]

The susceptibility and efficiency of CTC for identifying the location of colon tumors, according to Zhou et al.,[9] were 100% and 92.58%, correspondingly. CTC also showed an advanced favorable mark aimed at medical elimination of CC then CS (0–0.921 diagnosis certainty vs. 0–0.734 diagnostic confidence). It could never even make more than one continuous segment error in tumor localization. The results of the current investigation for CTC's sensitivity and accuracy in detecting the location of colon tumors remained comparable with that of prospective cohort studies and a comparative study. The investigative criteria for precolectomy location and T staging of colon tumors have improved thanks to CTC. Radiologists, however, show modest interobserver variability, according to the study's findings. In addition, these findings showed CTC has a compassionate, nonetheless low sensitivity of tumor stage and location, as well as being vulnerable to different readers.

  Conclusion Top

In summary, CTC with 16-MDCT exhibited a strong connection using the pathological TNM stage and became more sensitive in identifying tumors and polyps than CS. Our preliminary findings suggest that CTC might be effective for staging tumors and detecting polyps or malignancies in locations not visible on CCS in people with CRC. MDCT is a potential method for determining preliminary grading and prognosis in CC. Randomized trials with extensive sequence endure mandatory en route to demonstrate that effectiveness of MDCT for stages and establishing prognosis of CC. This research may lead to the developing of new preoperative staging and treatment guidelines for CC.

Payment/services info

All authors have declared that no financial support was received from any organization for the submitted work.

Other relationships

All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Financial support and sponsorship

All authors have declared that they have no financial relationships at present or within the previous years with any organizations that might have an interest in the submitted work.

Conflicts of interest

There are no conflicts of interest.

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