The Preoperative Staging of Rectal Cancer

  • Susan L. Gearhart
  • Jonathan E. Efron


The classification of a newly diagnosed cancer of the rectum into a staging system with both therapeutic and prognostic applications has been the goal of pathologists and clinicians for the greater part of the last century. Most staging systems rely on the examination of the pathological specimen as well as information gained during surgery. Thus, they are useful only in the postoperative setting and have little use for the purpose of preoperative therapy. Cuthberg Dukes declared in 1932 “If it would be possible to decide the category of the case before operating, this would be very useful information.”1 As the therapeutic options available for the treatment of rectal cancer increase, the ability to accurately stage a rectal tumor preoperatively takes on greater importance. Accurate and reproducible preoperative staging provides uniformity among numerous investigative centers; specifically, those involved in adjuvant preoperative therapy trials.


  1. 1.
    Dukes C. The classification of cancer of the rectum. J Pathol Bacteriol. 1932;35:323–32.CrossRefGoogle Scholar
  2. 2.
    York-Mason A. Rectal cancer. The spectrum of selective surgery. Proc R Soc Med. 1976;69:237–44.Google Scholar
  3. 3.
    Nicholls RJ, York-Mason A, Morson BC, et al. The clinical staging of rectal cancer. Br J Surg. 1982;69:404–9.CrossRefGoogle Scholar
  4. 4.
    Nogueras JJ. Endorectal ultrasonography: technique, image interpretation, and expanding indications in 1995. Semin Colon Rectal Surg. 1995;6:70–7.Google Scholar
  5. 5.
    Mor I, Hull T, Hammel J, Zutshi M. Rectal endosonography: just how good are we at its interpretation? Int J Colorectal Dis. 2010;25:87–90.CrossRefGoogle Scholar
  6. 6.
    Garcia-Aguilar J, Pollack J, Lee SH, et al. Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum. 2002;45:10–5.CrossRefGoogle Scholar
  7. 7.
    Puli S, Reddy J, Bechtold M, Choudhary A, Antillon M, Brugge W. Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancer: meta-analysis and systematic review. Ann Surg Onc. 2009;16:1255–65.CrossRefGoogle Scholar
  8. 8.
    Hunerbein M, Pegios W, Rau B, Vogl TJ, Felix R, Schlag PM. Prospective comparison of endorectal ultrasound, 3-D endorectal ultrasound, and endorectal MRI in the preoperative evaluation of rectal tumors. Preliminary results. Surg Endosc. 2000;14:1005–9.CrossRefGoogle Scholar
  9. 9.
    Kim JC, Cho YK, Kim SY, et al. Comparison study of three-dimensional and conventional endorectal ultrasounography used in rectal cancer staging. Surg Endosc. 2002;16(9):1280–5.CrossRefGoogle Scholar
  10. 10.
    Orrom WJ, Wong WD, Rothenberger DA, et al. Endorectal ultrasound in the preoperative staging of rectal tumors: a learning experience. Dis Colon Rectum. 1990;33:654–9.CrossRefGoogle Scholar
  11. 11.
    Rafaelsen S, Sorensen T, Jakobsen A, Bisgaard C, ­Lindebjerg J. Transrectal ultrasonography and magnetic resonance imaging in the staging of rectal cancer. Effect of experience. Scan J Gastroenterol. 2008;43:440–6.CrossRefGoogle Scholar
  12. 12.
    Hildebrandt U, Klein T, Fiefel G, et al. Endosonography of pararectal lymph nodes: in vitro and in vivo evaluation. Dis Colon Rectum. 1990;33:863–8.CrossRefGoogle Scholar
  13. 13.
    Harewood GC, Wiersema MJ, Nelson H, et al. A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer. Gastroenterology. 2002;123:24–32.CrossRefGoogle Scholar
  14. 14.
    Sentovich S, Blatchford G, Falk F, Thorson A, Christensen M. Transrectal US of rectal tumors. Am J Surg. 1993;166:638–41.CrossRefGoogle Scholar
  15. 15.
    Senesse P, Khemissa F, Lemar S, et al. Contribution of EUS in the preoperative evaluation of low rectal cancer. Gastroentérol Clin Biol. 2001;25:24–8.PubMedGoogle Scholar
  16. 16.
    Santoro G, D’Ella A, Battistella G, Di Falco G. The use of dedicated rectosigmoidoscope for US staging of tumors of the upper and middle third of the rectum. Colorectal Dis. 2007;9:61–6.CrossRefGoogle Scholar
  17. 17.
    Jhaveri K, Sdaf A. Role of MRI for staging of rectal cancer. Expert Rev Anticancer Ther. 2009;9:469–81.CrossRefGoogle Scholar
  18. 18.
    Kim NK, Kim MJ, Park JK, Park SIL, Min JS. Preoperative staging of rectal cancer with MRI: accuracy and clinical usefulness. Ann Surg Oncol. 2000;7(10):732–7.CrossRefGoogle Scholar
  19. 19.
    Brown G, Daniels IR. Preoperative staging of rectal cancer: the MERCURY research project. Recent Results Cancer Res. 2005;165:58–74.CrossRefGoogle Scholar
  20. 20.
    Brown G, Richard CJ, Williams GT, et al. Morphological predictors of lymph node status in rectal cancer using high spatial resolution magnetic resonance imaging with histopathological comparison. Radiology. 2003;90(3):355–64.Google Scholar
  21. 21.
    Lahaye M, Engelen S, Kessels A, et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: predictive criteria. Radiology. 2008;246:804–11.CrossRefGoogle Scholar
  22. 22.
    Quirke P, Durdey P, et al. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumor spread and surgical excision. Lancet. 1986;2:996–9.CrossRefGoogle Scholar
  23. 23.
    Adam IJ, Mohamdee MO, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–11.CrossRefGoogle Scholar
  24. 24.
    Hall NR, Finan PJ, et al. Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent: predictor of survival but not local recurrence? Dis Colon Rectum. 1998;41(8):979–83.CrossRefGoogle Scholar
  25. 25.
    Nagtegaal ID, Marijnen CA, et al. Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol. 2002;26(3):350–7.CrossRefGoogle Scholar
  26. 26.
    Marijnen CA, Nagtegaal ID, et al. Radiotherapy does not compensate for positive resection margins in rectal cancer patients: report of a multicenter randomized trial. Int J Radiat Oncol Biol Phys. 2003;55(5):1311–20.CrossRefGoogle Scholar
  27. 27.
    Beets-Tan RG. MRI in rectal cancer: the T stage and circumferential resection margin. Colorectal Dis. 2003;5(5):392–5.CrossRefGoogle Scholar
  28. 28.
    Branagan G, Chave H, et al. Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? Dis Colon Rectum. 2004;47(8):1317–22.CrossRefGoogle Scholar
  29. 29.
    Bipat S, Las A, Slors F, Zwinderman A, Bossuyt P, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MRI imaging – a meta-analysis. Radiology. 2004;232:773–83.CrossRefGoogle Scholar
  30. 30.
    Skandarajah A, Tjandra J. Preoperative loco-regional imaging in rectal cancer. ANZ J Surg. 2006;76:497–504.CrossRefGoogle Scholar
  31. 31.
    Bipat S, van Leeuwen M, Comans E, Pijil M, Bossuyt P, Zwinderman A, et al. Colorectal liver metastases: CT, MR imaging, and PET for diagnosis – meta-analysis. Radiology. 2005;237:123–31.CrossRefGoogle Scholar
  32. 32.
    Dixon AK, Frye IK, Morson BC, et al. Pre-operative computed tomography of carcinoma of the rectum. Br J Radiol. 1981;54:655–9.CrossRefGoogle Scholar
  33. 33.
    Thompson WM, Halvorsen RA, Foster Jr WL, et al. Pre-operative and post-operative CT staging of rectosigmoid carcinoma. AJR. 1986;146:703–10.CrossRefGoogle Scholar
  34. 34.
    Freeny PC, Marks WM, Tyan JA, et al. Colorectal carcinoma evaluation with CT: pre-operative staging and detection of post-operative recurrence. Radiology. 1986;158:347–53.CrossRefGoogle Scholar
  35. 35.
    Holdsworth PJ, Johnston D, Chalmers AG, et al. Endoluminal ultrasound and computed tomography in the staging of rectal cancer. Br J Surg. 1988;75:1019–22.CrossRefGoogle Scholar
  36. 36.
    Goldman S, Arvidsson H, Norming U, et al. Transrectal ultrasound and computed tomography in preoperative staging of lower rectal adenocarcinoma. Gastrointest Radiol. 1991;16:259–63.CrossRefGoogle Scholar
  37. 37.
    Zerhouni EA, Rutter C, Hamilton SR, et al. CT and MR imaging in the staging of colorectal carcinoma: report of the Radiology Diagnostics Oncology Group II. Radiology. 1996;200:443–51.CrossRefGoogle Scholar
  38. 38.
    Matsuoka H, Nakamura A, Masaki T, et al. Preoperative staging by multidetector-row computed tomography in patients with rectal carcinoma. Am J Surg. 2002;184:131–5.CrossRefGoogle Scholar
  39. 39.
    Chiesura-Corona M, Muzzio PC, Giust G, et al. Rectal cancer: CT local staging with histopathologic correlation. Abdom Imaging. 2001;26:134–8.CrossRefGoogle Scholar
  40. 40.
    Matsuoka H, Nakamura A, Masaki T, et al. A prospective comparison between multidetector-row computed tomography and magnetic resonance imaging in the preoperative evaluation of rectal carcinoma. Am J Surg. 2003;185(6):556–9.CrossRefGoogle Scholar
  41. 41.
    Whiteford MH, Whiteford HM, Yee LF, et al. Usefulness of FDG-PET scan in the assessment of suspected metastatic or recurrent adenocarcinoma of the colon and rectum. Dis Colon Rectum. 2000;43(6):759–67.CrossRefGoogle Scholar
  42. 42.
    Cohade C, Osman MM, Leal J, Wahl RL. Direct comparison of (18)F-FDG PET and PET/CT in patients with colorectal carcinoma. J Nucl Med. 2003;44(11):1804–5.Google Scholar
  43. 43.
    Cohade C, Osman M, Leal J, Wahl RL. Direct comparison of (18)F-FDG PET and PET/CT in patients with colorectal carcinoma. J Nucl Med. 2003;44(11):1797–803.PubMedGoogle Scholar
  44. 44.
    Heriot AG, Hicks RJ, Drummond EGP, et al. Does positron emission tomography change management in primary rectal cancer? A prospective assessment. Dis Colon Rectum. 2004; 47(4):451–8.CrossRefGoogle Scholar
  45. 45.
    Gearhart SL, Frassica D, Rossen R, Choti M, Schulick R, Wahl R. Improved staging with pre-treatment PET/CT in low rectal cancer. J Surg Oncol. 2006;13(3):397–404.CrossRefGoogle Scholar
  46. 46.
    Napoleon B, Pujol B, Berger F, et al. Accuracy of endosonography in the staging of rectal cancer treated by radiotherapy. Br J Surg. 1991;78:785–8.CrossRefGoogle Scholar
  47. 47.
    Kim SH, Lee JM, Hong SH, et al. Locally advanced rectal cancer: added value of diffusion-weighted MR imaging in the evaluation of tumor response to neoadjuvant chemoradiotherapy. Radiology. 2009;253(1):116–25.CrossRefGoogle Scholar
  48. 48.
    Melton G, Lavely W, Jacene H, Schulick R, Choti M, Wahl R, et al. Efficacy of preoperative combined 18-fluorodeoscyglucose positron emission tomography and computed tomography for assessing primary rectal cancer response to neoadjuvant therapy. J Gastrointest Surg. 2007;11(8):961–9.CrossRefGoogle Scholar
  49. 49.
    Guillem JG, Puig-La Calle Jr J, Akurst T. Prospective assessment of primary rectal cancer response to preoperative radiation and chemotherapy using 18-flourodeoxyglucose positron emission tomography. Dis Colon Rectum. 2000;43(1):18–24.CrossRefGoogle Scholar
  50. 50.
    Delrio P, Lastoria S, Avallone A, et al. Early evaluation using PET-FDG of the efficiency of neoadjuvant radiochemotherapy treatment in locally advanced neoplasia of the lower rectum. Tumori. 2003;89(4 Suppl):50–3.PubMedGoogle Scholar
  51. 51.
    Capirci C, Rubello D, Pasini F, et al. The role of dual-time combined 18-Fluoridedoexyglucose positron emission tomography and computed tomography in the staging and restaging workup of locally advanced rectal cancer, treated with preoperative chemoradiation therapy and radical surgery. Int J Radiat Oncol Biol Phys. 2009;74:1461–9.CrossRefGoogle Scholar
  52. 52.
    Janssen M, Ollers M, Riedel R, et al. Accurate prediction of pathological rectal tumor response after 2 weeks of preoperative radiochemotherapy using 18fluorodeoxyglucose-positron emission tomography-computed tomography imaging. Int J Radiat Oncol Biol Phys. 2009;4:1–8.Google Scholar
  53. 53.
    Wieder H, Geinitz H, Rosenberg R, et al. PET imaging with 18-F-3-doxy-3-fluorothympidine for prediction of response to neoadjuvant treatment in patients with rectal cancer. Eur J Nucl Med Mol Imaging. 2007;34:878–83.CrossRefGoogle Scholar
  54. 54.
    Amthauer H, Deneke T, Rau N. Response prediction by FDG-PET after neoadjuvant radiochemotherapy and combined hyperthermia of rectal cancer. Eur J Nulc Med Mol Imaging. 2004;31:811–9.CrossRefGoogle Scholar
  55. 55.
    Chessin B, Akhurst T, Yeung H. Positron emission tomography during preoperative combined modality therapy for rectal cancer may predict ultimate pathologic response: a prospective analysis. J Clin Oncol. 2005;16:3612.CrossRefGoogle Scholar
  56. 56.
    Denke T, Rau N, Hoffmann K. Comparison of CT, MRI, and FDG-PET in response prediction of patients with locally advanced rectal cancer after multimodal preoperative therapy; is there a benefit in using functional imaging? Eur Radiol. 2005;15:1658–66.CrossRefGoogle Scholar
  57. 57.
    Kim S, Lee J, Hong S, Kim G, Lee J, Han J, et al. Locally advanced rectal cancer: added value of diffusion-weighted MR imaging in the evaluation of tumor response to neoadjuvant chemo-radiation therapy. Radiology. 2009;1:116–25.CrossRefGoogle Scholar

Copyright information

© ASCRS (American Society of Colon and Rectal Surgeons) 2011

Authors and Affiliations

  • Susan L. Gearhart
    • 1
  • Jonathan E. Efron
    • 2
  1. 1.Department of SurgeryJohns Hopkins Medical InstitutionBaltimoreUSA
  2. 2.Department of SurgeryJohns Hopkins HospitalBaltimoreUSA

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