Imaging Metastatic Rectal Cancer

Jack Temple, MS3

June 2013

Christian Malalis, MD

• JS is a 77 year old man with a history of sigmoid colon cancer (s/p sigmoid resection w/o adjuvant therapy in 2009)

• Surveillance colonoscopy at OSH on 4/17/13 revealed large rectal mass referred to Rush GI and Colorectal surgery

• Rush GI performed:– Flexible Sigmoidoscopy (5/22/13)

– Transrectal Ultrasound (5/22/13)

• Rush Radiology consulted for:– Staging purposes

Clinical History / Physical Exam

Rush Endoscopy Images

Flexible Sigmoidoscopy Images, Courtesy of David Shapiro, MD; 5/22/13

Transrectal Ultrasound

Transrectal Ultrasound Images, Courtesy of David Shapiro, MD; 5/22/13

Colorectal Cancer Staging

Image Source:http://www.hopkinscoloncancercenter.org/

Rectal Cancer Metastasis

Image Source:http://www.elsevierimages.com/

• For pre-treatment staging of colorectal cancer (large lesion):

ACR Appropriateness Criteria

Procedure Rating RRL

CT chest, abdomen, pelvis with contrast

8

FDG-PET/CT whole body 8

X-Ray chest 8

MRI pelvis with and without contrast

8 0

MRI abdomen with and without contrast

7 0

Source: ACR appropriateness criteria

Pelvis (normal)

Axial CT

(No MRN)

Source: e-Anatomy(www.imaios.com)

Pelvis (our patient)

Axial CT from PET/CT

MRN-6557254

Pelvis (our patient)

Axial Fused PET/CT MRN-6557254

Pelvis (normal)

Axial CT

(No MRN)

Source: e-Anatomy(www.imaios.com)

Pelvis (our patient)

Axial CT From PET/CT

MRN-6557254

Pelvis (our patient)

Axial Fused PET/CT

MRN-6557254

Abdomen (normal)

Axial CT(No MRN)

Source: e-Anatomy(www.imaios.com)

Abdomen (our patient)

Axial CT from PET/CT

MRN-6557254

Abdomen (our patient)

Axial Fused PET/CT

MRN-6557254

Abdomen (our patient)

Diagnostic CT post contrast MRN-6557254

Axial

Coronal

• Treatment:–Most cases, treatment is palliative3

• Prolong survival and maintain quality of life

– Chemo options• Old: 5-Fluorouracil

• New: Irinotecan, Oxaliplatin

• Monoclonal Abs: Cetuximab, Panitumumab, Aflibercept4

– Surgical resection

• Follow up imaging:– Surveillance imaging

Treatment and Follow Up Imaging

Images:

• www.hopkinscoloncancercenter.org/

• www.elsevierimages.com

• www.imaios.com (e-Anatomy)

• www.gruntdoc.com

References:

1. Bipat S, Glas AS, et al. Rectal Cancer: Local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging—a meta-analysis. Radiology 2004 Sep; 232(3): 773-83.

2. American College of Radiology Appropriateness Criteria: Pretreatment Staging of Colorectal Cancer, 2011.

3. Weeks JC, Catalano PJ, et. al. Patients’ expectations about effects of chemotherapy for advanced cancer. New England Journal of Medicine 2012; 367: 1616-25.

4. Clark JW, Grothey A. Systemic chemotherapy for nonoperable metastatic colorectal cancer: treatment recommendations. UpToDate 2013.

5. Flamen P, Hoekstra OS, et al. Unexplained rising carcinoembryonic antigen (CEA) in the postoperative surveillance of colorectal cancer: the utility of positron emission tomography (PET). European

Journal of Cancer 2001; 37(7): 862.

References

Christian Malalis, MD, PGY IV

Rush Endoscopy

David Shapiro, MD

Thanks!

The End

Source:www.gruntdoc.com