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How Reliable Is CT Scan in Staging Right Colon Cancer?

Fernandez, Laura M. M.D.1; Parlade, Albert J. M.D.2; Wasser, Elliot J. M.D.2; Dasilva, Giovanna M.D.1; de Azevedo, Rafael U. M.D.3; Ortega, Cinthia D. M.D.3; Perez, Rodrigo O. M.D., Ph.D.3; Habr-Gama, Angelita M.D., Ph.D.3; Berho, Mariana M.D.4; Wexner, Steven D. M.D., Ph.D. (Hon.)1

Diseases of the Colon & Rectum: August 2019 - Volume 62 - Issue 8 - p 960–964
doi: 10.1097/DCR.0000000000001387
Original Contributions: Colorectal Cancer
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BACKGROUND: The observation of inferior oncologic outcomes after surgery for proximal colon cancers has led to the investigation of alternative treatment strategies, including surgical procedures and neoadjuvant systemic chemotherapy in selected patients.

OBJECTIVE: The purpose of this study was to determine the accuracy of CT staging in proximal colon cancer in detecting unfavorable pathologic features that may aid in the selection of ideal candidates alternative treatment strategies, including extended lymph node dissection and/or neoadjuvant chemotherapy.

DESIGN: This was a retrospective consecutive series.

SETTINGS: Trained abdominal radiologists from 2 centers performed a blinded review of CT scans obtained to locally stage proximal colon cancer according to previously defined prognostic groups, including T1/2, T3/4, N+, and extramural venous invasion. CT findings were compared with histopathologic results as a reference standard. Unfavorable pathologic findings included pT3/4, pN+, or extramural venous invasion.

PATIENTS: Consecutive patients undergoing right colectomy in 2 institutions between 2011 and 2016 were retrospectively reviewed from a prospectively collected database.

MAIN OUTCOME MEASURES: T status, nodal status, and extramural venous invasion status comparing CT with final histologic findings were measured.

RESULTS: Of 150 CT scans reviewed, CT failed to identify primary cancer in 18%. Overall accuracy of CT to identify unfavorable pathologic features was 63% with sensitivity, specificity, positive predictive value, and negative predictive value of 63% (95% CI, 54%–71%), 63% (95% CI, 46%–81%), 87% (95% CI, 80%–94%) and 30% (95% CI, 18%–41%). Only cT3/4 (55% vs 45%; p = 0.001) and cN+ (42% vs 58%; p = 0.02) were significantly associated with correct identification of unfavorable features at final pathology. CT scans overstaged and understaged cT in 23.7% and 48.3% and cN in 28.7% and 53.0% of cases.

LIMITATIONS: The study was limited by its retrospective design, relatively small sample size, and heterogeneity of CT images performed in different institutions with variable equipment and technical details.

CONCLUSIONS: Accuracy of CT scan for identification of pT3/4, pN+, or extramural venous invasion was insufficient to allow for proper identification of patients at high risk for local recurrence and/or in whom to consider alternative treatment strategies. Locoregional overstaging and understaging resulted in inappropriate treatment strategies in <48%. See Video Abstract at http://links.lww.com/DCR/A935.

1 Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida

2 Imaging Department, Cleveland Clinic Florida, Weston, Florida

3 Angelita & Joaquim Gama Institute, São Paulo, Brazil

4 Department of Pathology, Cleveland Clinic Florida, Weston, Florida

Earn Continuing Education (CME) credit online at cme.lww.com.

Funding/Support: None reported.

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017 and at the annual meeting of the Association for Coloproctology of Great Britain and Ireland, Bournemouth, UK, July 3-5, 2017.

Correspondence: Steven D. Wexner, M.D., Ph.D. (Hon.), Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331. E-mail: wexners@ccf.org

© 2019 The American Society of Colon and Rectal Surgeons