Adrenal Incidentalomas During Diagnostic Work-up of Colorectal Cancer Patients: What is the Risk of Metastases?

BACKGROUND: Adrenal incidentalomas (AIs) are regularly discovered on staging computed tomography (CT) of patients with colorectal cancer (CRC). Although CRC is considered unlikely to metastasize to the adrenal gland, it is not known how often an AI appears to be a CRC metastasis. This causes a diagnostic dilemma for many patients with newly diagnosed CRC. This study aimed primarily to describe the incidence of AIs and adrenal metastases in CRC patients. METHODS: A single-center cohort of 475 consecutive patients with newly diagnosed CRC was defined. Retrospectively, all radiology reports and multidisciplinary team meeting reports were assessed for the presence of adrenal abnormalities. All AIs shown on staging CT were reevaluated for the purpose of this study, and the sizes of these adrenal glands were determined. Based on the CT reevaluation, follow-up imaging, and clinical follow-up assessment, conclusions on the presence or absence of adrenal metastases were drawn. RESULTS: The incidence of AIs in this CRC patient cohort was 10.5% (50/475). In 96% (48/50) of the patients with AIs, adrenal metastases could be ruled out. No solitary adrenal metastases were encountered. In two patients who had widespread systemic disease without curative treatment options, the AIs were considered to be adrenal metastases (cohort incidence, 0.4%). CONCLUSION: This is the first study to report on adrenal incidentalomas in CRC patients. In newly diagnosed CRC patients without disseminated disease, AIs can be considered benign, and no additional imaging is indicated to rule out adrenal metastases in this group.

Accuracy of MRI in Restaging Locally Advanced Rectal Cancer After Preoperative Chemoradiation.

BACKGROUND: Patients with a locally advanced rectal carcinoma benefit from preoperative chemoradiotherapy. MRI is considered the first choice imaging modality after preoperative chemoradiation, although its reliability for restaging is debatable. OBJECTIVE: The purpose of this study was to determine the accuracy of MRI in restaging locally advanced rectal cancer after preoperative chemoradiation. DESIGN: This was a retrospective study. SETTINGS: The study was conducted in a Dutch high-volume rectal cancer center. PATIENTS: A consecutive cohort of 48 patients with locally advanced rectal cancer treated with a curative intent was identified. MAIN OUTCOME MEASURES: Three readers independently evaluated the MRI both for primary staging and for restaging after preoperative chemoradiation and were blinded to results from the other readers as well as histological results. Interobserver variability was determined. Accuracy of the restaging MRI was assessed through the comparison of tumor characteristics on MRI with histopathologic outcomes. RESULTS: T stage was correctly predicted by the 3 readers in 47% to 68% and N stage in 68% to 70%. Overstaging was more common than understaging. Positive predictive values (PPV) among the 3 readers for T0 were 0%, and negative predictive values (NPVs) varied from 84% to 85%. For T1/2, PPVs and NPVs were 50% to 67% and 72% to 90%, and for T3/4 they were 54% to 62% and 33% to 78%. PPVs and NPVs for N0 stage were 81% to 95% and 58% to 73%. Tumor regression grade on MRI did not correspond with histopathologic tumor regression grade; PPVs for good response (tumor regression grade on MRI 1-2) were 48% to 61%, and NPVs were 42% to 58%. Interobserver agreement was fair to moderate for T stage, N stage, and tumor response (κ = 0.20-0.41) and fair to substantial for the relation with the mesorectal fascia (κ = 0.33-0.77). In none of the patients was the surgical plan changed after the restaging MRI. LIMITATIONS: This study was limited by its small sample size and retrospective nature. CONCLUSIONS: MRI has low accuracy for restaging locally advanced rectal cancer after preoperative chemoradiation, and the interobserver variability is significant.

A prediction model for lung metastases in patients with indeterminate pulmonary nodules in newly diagnosed colorectal cancer.

INTRODUCTION: Multidisciplinary teams treating patients with newly diagnosed Colorectal Cancer (CRC) often encounter the appearance of Indeterminate Pulmonary Nodules (IPNs) that warrants follow-up with repetitive medical imaging and anxiety for patients. We determined the incidence of IPNs in patients with newly diagnosed CRC and developed and validated a model for individualized risk prediction of IPNs being lung metastases. MATERIAL AND METHODS: Newly diagnosed CRC who underwent surgery between November 2011 to June 2014 were included to create the risk model, developed using both clinical experience and statistical selection. Discrimination and calibration slopes of the risk score were evaluated in an independent temporal validation sample. A nomogram is presented to assist clinicians in estimating an individual risk score. RESULTS: Out of 2111 CRC patients staged with chest CT, 204 (9.6%) had IPNs and 54/204 (26%) had lung metastases. We identified 4 predictors: "location of primary tumour", "pathological nodal stage", "size of the largest nodule" and "extrapulmonary synchronous metastases at diagnosis". Discrimination of the final model in the validation sample was demonstrated by the difference in mean predicted risk between progressed cases en non-progressed cases (49% versus 21%, p = <0.001). CONCLUSION: A prediction model with 4 clinical risk factors can be used to assist multidisciplinary teams in the prediction of individualized risk of lung metastases and imaging strategy in patients with IPNs and newly diagnosed colorectal cancer. The model performed well in new patients not included in the model development.

The incidence and natural course of occult inguinal hernias during TAPP repair: repair is beneficial.

BACKGROUND: One of the proposed advantages of laparoscopic inguinal hernia repair is complimentary inspection of the contralateral side and possible detection of occult hernias. Incidence of occult contralateral hernias is as high as 50 %. The natural course of such occult defects is unknown and therefore operative rationale is lacking. This study was designed to analyze the incidence of occult contralateral inguinal hernias and its natural course. METHODS: A total of 1,681 patients were diagnosed preoperatively with unilateral inguinal hernia. None of these patients had complaints of the contralateral side preoperatively. All patients underwent laparoscopic inguinal hernia transabdominal preperitoneal (TAPP) repair. Operative details were analyzed retrospectively. Patients with occult contralateral defects were identified and tracked. Patients with an evident occult hernia received immediate repair. Patients with a smaller beginning or incipient hernia were followed. RESULTS: In 218 (13 %) patients, an occult hernia was found at the contralateral side during preoperative exploration. In 129 (8 %) patients, an occult true hernia was found. In 89 (5 %) patients, an occult incipient hernia was found. An incipient hernia was defined as a beginning hernia. All patients with an incipient hernia were followed. The mean follow-up was 112 (range 16-218) months. Twenty-eight (32 %) patients were lost to follow-up. In the 61 remaining patients, 13 (21 %) occult incipient hernias became symptomatic requiring repair. The mean time between primary repair and development of a symptomatic hernia on the contralateral side was 88 (range 24-210) months. CONCLUSIONS: This study shows that the incidence of occult contralateral hernias is 13 % during TAPP repair of unilateral diagnosed inguinal hernias. In 5 % of the cases, the occult hernia consisted of a beginning hernia. Eventually, one of five will become symptomatic and require repair. These outcomes support immediate repair of occult defects, no matter its size.

Indeterminate Liver Lesions in Patients With Early Stage Rectal Cancer: Can They Be Ignored?

PURPOSE: Small, hypoattenuating, indeterminate liver lesions are often encountered during staging computed tomography (CT) in patients with early-stage rectal cancer. This study aimed to determine the incidence and prognostic significance of these lesions. METHODS AND MATERIALS: A single institution's colorectal cancer (CRC) database was searched for patients with early-stage rectal cancer, defined as a cT1-2N0 tumor on magnetic resonance imaging (MRI). Abdominal CT scans of these patients were assessed for the presence of liver lesions and categorized according to their morphology. Preoperative MRI scans of the liver and abdominal follow-up imaging were assessed to determine whether the liver lesions found during staging CT appeared to be CRC metastases or not. RESULTS: In a consecutive cohort of 1232 patients with CRC who had undergone surgery, 84 patients with early-stage rectal cancer (cT1-2N0 on MRI) were identified. Of those 84 patients, 45 (54%) had 1 or more liver lesions on staging CT; a total of 122 liver lesions were observed, consisting of 95 indeterminate lesions (78%), 25 cysts (20%), and 2 hemangiomas (2%). Preoperative MRI of the liver and regular follow-up imaging revealed no synchronous or metachronous liver metastases in this cohort. CONCLUSIONS: In this study, small, hypoattenuating, indeterminate lesions of the liver were common in patients diagnosed with early rectal cancer and seemed to have no clinical significance. Additional preoperative imaging or follow-up imaging for indeterminate liver lesions in such patients may be unnecessary.

Dealing with indeterminate pulmonary nodules in colorectal cancer patients; a systematic review.

INTRODUCTION: Indeterminate pulmonary nodules (IPNs) are frequently encountered on staging computed tomography (CT) in colorectal cancer (CRC) patients and they create diagnostic dilemmas. This systematic review and pooled analysis aims to estimate the incidence and risk of malignancy of IPNs and provide an overview of the existing literature on IPNs in CRC patients. MATERIALS AND METHODS: EMBASE, Pubmed and the Cochrane database were searched for papers published between January 2005 and April 2020. Studies describing the incidence of IPNs and the risk of malignancy in CRC patients and where the full text was available in the English language were considered for inclusion. Exclusion criteria included studies that used chest X-ray instead of CT, liver metastasis cohorts, studies with less than 60 CRC patients and reviews. RESULTS: A total of 18 studies met the inclusion criteria, involving 8637 patients. Pooled analysis revealed IPNs on staging chest CT in 1327 (15%) of the CRC patients. IPNs appeared to be metastatic disease during follow up in 16% of these patients. Regional lymph node metastases, liver metastases, location of the primary tumour in the rectum, larger IPN size and multiple IPNs are the five most frequently reported parameters predicting the risk of malignancy of IPNs. CONCLUSION: A risk stratification model for CRC patients with IPNs is warranted to enable an adequate selection of high risk patients for IPN follow up and to diminish the use of unnecessary repetitive chest CT-scans in the many low risk patients.

Prospective, Multicenter Validation Study of Magnetic Resonance Volumetry for Response Assessment After Preoperative Chemoradiation in Rectal Cancer: Can the Results in the Literature be Reproduced?

PURPOSE: To review the available literature on tumor size/volume measurements on magnetic resonance imaging for response assessment after chemoradiotherapy, and validate these cut-offs in an independent multicenter patient cohort. METHODS AND MATERIALS: The study included 2 parts. (1) Review of the literature: articles were included that assessed the accuracy of tumor size/volume measurements on magnetic resonance imaging for tumor response assessment. Size/volume cut-offs were extracted; (2) Multicenter validation: extracted cut-offs from the literature were tested in a multicenter cohort (n=146). Accuracies were calculated and compared with reported results from the literature. RESULTS: The review included 14 articles, in which 3 different measurement methods were assessed: (1) tumor length; (2) 3-dimensonial tumor size; and (3) whole volume. Study outcomes consisted of (1) complete response (ypT0) versus residual tumor; (2) tumor regression grade 1 to 2 versus 3 to 5; and (3) T-downstaging (ypT

Avances en cirugía del cáncer de recto: recorrido histórico y nuevas perspectivas después del estudio COLOR II / State of the art in rectal cancer surgery: Historical overview and new perspectives after the COLOR II trial

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