RESUMO
BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) is associated with post-operative anastomotic complications in rectal-cancer patients. Anastomosis involving at least one non-irradiated margin reportedly significantly reduces the risk of post-operative anastomotic complications in radiation enteritis. However, the exact scope of radiotherapy on the remaining sigmoid colon remains unknown. METHODS: We evaluated the radiation damage of proximally resected colorectal segments in 44 patients with rectal cancer, who received nCRT followed by conventional resection (nCRT-C, n = 21) or proximally extended resection (nCRT-E, n = 23). The segments from another 13 patients undergoing neoadjuvant chemotherapy (nCT) were used as control. We dissected these samples at a distance of 2 cm between the two adjacent sections. Radiation damage in proximally resected colorectal segments was evaluated using the radiation injury score (RIS) and the concentration and distribution patterns of angiostatin. RESULTS: Compared to those in the nCT group, the nCRT group showed higher RIS, levels of angiostatin, and proportion of diffuse pattern of angiostatin. With increasing distance from the tumor site, these parameters all gradually decreased; and the differences came to be not significant at the site that is over 20 cm from the tumor. The nCRT-E group showed lower RIS (median: 2 vs 4, P = 0.002) and a greater proportion of non-diffuse angiostatin (87% vs 55%, P = 0.039) at the proximal margins compared with the nCRT-C group. CONCLUSIONS: The severity of the radiation damage of the proximal colon is inversely proportional to the proximal-resection margin length. Little damage was left on the proximal margin that was over 20 cm from the tumor. Removal of an initial length of ≥20 cm from the tumor may be beneficial for rectal-cancer patients after nCRT.
RESUMO
The aim of this study was to summarize the imaging features of chronic radiation proctitis (CRP) on endorectal ultrasound (ERUS) and investigate the value of ERUS in the evaluation of disease activity. 40 CRP patients and 30 control patients were investigated by ERUS. Rectal wall thickness and layers, ulcers and rectovaginal fistulas were evaluated by B-mode ultrasound. Power Doppler imaging was used to evaluate the vascularity of the rectal wall using a semiquantitative score. Disease activity was calculated according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 (CTCAE 4.0). Imaging findings for patients with mild and severe CRP were compared. For 30 patients in the control group, the average maximum thickness of the rectal wall was 3.07 ± 0.73 mm, with all exhibiting typical wall stratification and level 0 vascularity. For the 40 CRP patients, there was marked thickening of the rectal wall (average thickness = 9.42 ± 1.94 mm), which was significantly thicker than in the control group (p < 0.05). The rectal walls of the mild group were significantly thinner than those of the severe group (8.71 ± 1.67 mm vs. 10.00 ± 2.00 mm, p < 0.05). Among the 22 severe cases, 19 cases (19/22, 86.4%) exhibited hyper-vascularity (level IV) or blurred wall stratification (including hypo-echoic submucosa, ulcer and fistula); 12 of the 18 mild cases (166.7%) exhibited a vascularity of level III and typical wall stratification. A significant association (p < 0.05) was observed between stratification and vascularity of the rectal wall and CRP activity. When ERUS findings of blurred rectal wall stratification or increasing vascularity (level IV) were used to evaluate CRP activity, the sensitivity was 86.4% (95% confidence interval: 64.0-96.4) and the specificity was 66.7% (95% confidence interval: 41.2-85.6). Thickening of the rectal wall, blurred wall stratification and increased vascularity are characteristic ERUS findings of CRP. ERUS is helpful in the comprehensive evaluation of disease activity and may provide objective evidence during treatment planning and follow-up.