Optimale präoperative Diagnostik beim Rektumkarzinom

Zusammenfassung

Ziel der präoperativen Diagnostik beim Rektumkarzinom ist die Erfassung des Ausmaßes der lokalen und systemischen Tumorausbreitung. Das lokale Staging umfasst die Rektoskopie mit exakter Höhenlokalisation, die histologische Sicherung, die MRT des Beckens und – insbesondere bei lokal begrenzten Tumoren – die Endosonografie. Die Befundung der MRT sollte neben der Höhe des Tumors und der möglichen Infiltration von Nachbarorganen den minimalen Abstand des Tumors zur mesorektalen Faszie enthalten. Wichtig ist zudem die Angabe MR-morphologischer Kriterien extramuraler Gefäßinvasion. Bei tiefen Karzinomen ist der Bezug zu den einzelnen Komponenten des Schließmuskels eine wichtige Frage an die MRT zur Planung der operativen Strategie, bei hohen Karzinomen sollte auf eine mögliche Infiltration der peritonealen Umschlagfalte geachtet werden. Zum Nachweis oder Ausschluss von Fernmetastasen stellt ein Röntgenthorax und eine Sonografie des Abdomens die durch die Leitlinie geforderte Basisdiagnostik dar. Entweder primär, in jedem Fall aber bei unklaren Befunden, sollten diese durch ein Thorax- und Abdomen-CT ergänzt werden. Neben der Bestimmung des karzinoembryonalen Antigens (CEA), das vorrangig zur Verlaufskontrolle dient, sollte eine vollständige Koloskopie zum Ausschluss eines Zweitmalignoms im Kolon erfolgen. Ist diese aufgrund eines nicht passierbaren Tumors nicht möglich, dann sollte diese 3 Monate postoperativ erfolgen. Ergänzend kann eine präoperative CT- oder MR-Kolonoskopie erfolgen, mit der größere Polypen und Karzinome nachgewiesen werden können.

Abstract

Preoperative diagnostics for rectal cancer aim to determine the extent of local and systemic spread. Local staging includes rectoscopy with accurate height localisation, histological confirmation, MRI of the pelvis and, particularly in the case of localised tumours, endosonography. In addition to tumour height and possible infiltration of adjacent organs, MRI findings should include minimum tumour distance from the mesorectal fascia and MR morphological criteria for extramural vascular invasion. In the case of lower rectal cancer, the relationship to the various components of the sphincter muscle is important in planning the surgical strategy; in the case of upper rectal cancer, the MRI findings should include possible infiltration of the peritoneal fold. As outlined in the German guidelines, the basic diagnostic tests required to detect or exclude distant metastases are a chest X-ray and an abdominal ultrasound. If unclear findings are observed, these should be supplemented by a chest and abdominal CT. In addition to the carcinoembryonic antigen (CEA) test, which is primarily used for follow-up, a complete colonoscopy should be performed to rule out a second malignancy in the colon. If this is not possible due to an obstructive tumour, the colonoscopy should be performed three months postoperatively. Additionally, a preoperative CT or MR colonoscopy can reliably detect larger polyps and carcinomas.

Schlüsselwörter

Rektumresektion - Rektumkarzinom - MRT - bildgebende Verfahren - Krebs

Keywords

colon surgery - colorectal carcinoma - MRI - imaging methods - cancer

Publikationsverlauf

Eingereicht: 27. Januar 2025

Angenommen nach Revision: 10. März 2025

Artikel online veröffentlicht:
08. April 2025

• Literatur

• 1 Kreis ME. Magnetresonanztomographie (MRT)-basierte Chirurgie des Rektumkarzinoms. MRT-basierte Chirurgie des Rektumkarzinoms. In: Kreis ME, Asbach P. , Hrsg. . BerlinHeidelberg: Springer; 2020: 89-93
• 2 Deutsche Krebsgesellschaft, Deutsche Krebshilfe, Leitlinienprogramm Onkologie. S3-Leitlinie Kolorektales Karzinom, Langversion 2.1 – Januar 2019. AWMF-Registernummer: 021/007OL.
• 3 Schneider R, Schneider C, Büttner R. et al. [Colorectal Carcinoma with Suspected Lynch Syndrome: A Multidisciplinary Algorithm]. Zentralbl Chir 2015; 140: 591-599
• 4 Jasperson KW, Tuohy TM, Neklason DW. et al. Hereditary and familial colon cancer. Gastroenterology 2010; 138: 2044-2058
• 5 Cirillo L, Urso ED, Parrinello G. et al. High risk of rectal cancer and of metachronous colorectal cancer in probands of families fulfilling the Amsterdam criteria. Ann Surg 2013; 257: 900-904
• 6 Krasnick BA, Kalady MF. Management of Rectal Cancer in Lynch Syndrome: Balancing Risk Reduction and Quality of Life. Clin Colon Rectal Surg 2023; 37: 180-184
• 7 Goecke T, Schulmann K, Engel C. et al. Genotype-phenotype comparison of German MLH1 and MSH2 mutation carriers clinically affected with lynch syndrome: A report by the German HNPCC consortium. J Clin Oncol 2006; 24: 4285-4292
• 8 Win AK, Parry S, Parry B. et al. Risk of metachronous colon cancer following surgery for rectal cancer in mismatch repair gene mutation carriers. Ann Surg Oncol 2013; 20: 1829-1836
• 9 de Rosa N, Rodriguez-Bigas MA, Chang GJ. et al. DNA Mismatch Repair Deficiency in Rectal Cancer: Benchmarking Its Impact on Prognosis, Neoadjuvant Response Prediction, and Clinical Cancer Genetics. J Clin Oncol 2016; 34: 3039-3046
• 10 Klein F. Vorschau auf die S3-Leitlinie zum kolorektalen Karzinom. Zugriff am 25. Februar 2025 unter: https://www.springermedizin.de/dgvs-2024/kolorektales-karzinom/vorschau-auf-die-s3-leitlinie-zum-kolorektalen-karzinom/50097132
• 11 Cercek A, Lumish M, Sinopoli J. et al. PD-1 Blockade in Mismatch Repair-Deficient, Locally Advanced Rectal Cancer. N Engl J Med 2022; 386: 2363-2376
• 12 Glynne-Jones R, Wyrwicz L, Tiret E. et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28: iv22-iv40
• 13 Beyer K. Präoperatives Staging des Rektumkarzinoms. MRT-basierte Chirurgie des Rektumkarzinoms. In: Kreis ME, Asbach P. , Hrsg. . Berlin, Heidelberg: Springer; 2020: 71-78
• 14 Puli SR, Bechtold ML, Reddy JBK. et al. How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review. Ann Surg Oncol 2009; 16: 254-265
• 15 Luglio G, Pagano G, Tropeano FP. et al. Endorectal Ultrasonography and Pelvic Magnetic Resonance Imaging Show Similar Diagnostic Accuracy in Local Staging of Rectal Cancer: An Update Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 12: 5
• 16 Marusch F, Koch A, Schmidt U. et al. Routine use of transrectal ultrasound in rectal carcinoma: results of a prospective multicenter study. Endoscopy 2002; 34: 385-390
• 17 Detering R, van Oostendorp SE, Meyer VM. et al. MRI cT1–2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020; 107: 1372-1382
• 18 Li XT, Sun YS, Tang L. et al. Evaluating local lymph node metastasis with magnetic resonance imaging, endoluminal ultrasound and computed tomography in rectal cancer: a meta-analysis. Colorectal Dis 2015; 17: O129-O135
• 19 Puli SR, Reddy JBK, Bechtold ML. et al. Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review. Ann Surg Oncol 2009; 16: 1255-1265
• 20 Kav T, Bayraktar Y. How useful is rectal endosonography in the staging of rectal cancer?. World J Gastroenterol 2010; 16: 691-697
• 21 Tsai C, Hague C, Xiong W. et al. Evaluation of endorectal ultrasound (ERUS) and MRI for prediction of circumferential resection margin (CRM) for rectal cancer. Am J Surg 2017; 213: 936-942
• 22 Ye D, Zhu Z, Chen F. et al. Correlation Between Endorectal Ultrasound and Magnetic Resonance Imaging for Predicting the Circumferential Resection Margin in Patients With Mid-Low Rectal Cancer Without Preoperative Chemoradiotherapy. J Ultrasound Med 2020; 39: 569-577
• 23 Beets-Tan RGH, Lambregts DMJ, Maas M. et al. Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 2018; 28: 1465-1475
• 24 Taylor FGM, Quirke P, Heald RJ. et al. Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol 2014; 32: 34-43
• 25 Patel UB, Taylor F, Blomqvist L. et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol 2011; 29: 3753-3760
• 26 Kreis ME, Ruppert R, Kube R. et al. MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial. Ann Surg Oncol 2020; 27: 417-427
• 27 Tan JJ, Carten RV, Babiker A. et al. Prognostic Importance of MRI-Detected Extramural Venous Invasion in Rectal Cancer: A Literature Review and Systematic Meta-Analysis. Int J Radiat Oncol Biol Phys 2021; 111: 385-394
• 28 Memon S, Lynch AC, Bressel M. et al. Systematic review and meta-analysis of the accuracy of MRI and endorectal ultrasound in the restaging and response assessment of rectal cancer following neoadjuvant therapy. Colorectal Disease 2015; 17: 748-761
• 29 Garcia-Aguilar J, Patil S, Gollub MJ. et al. Organ Preservation in Patients With Rectal Adenocarcinoma Treated With Total Neoadjuvant Therapy. J Clin Oncol 2022; 40: 2546-2556
• 30 AIO Arbeitsgemeinschaft Internistische Onkologie in der Deutschen Krebsgesellschaft e. V.. Stellungnahmen. Zugriff am 08. März 2025 unter: https://www.aio-portal.de/stellungnahmen.html
• 31 de Jong EA, ten Berge JCEM, Dwarkasing RS. et al. The accuracy of MRI, endorectal ultrasonography, and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy: A metaanalysis. Surgery 2016; 159: 688-699
• 32 Fokas E, Appelt A, Glynne-Jones R. et al. International consensus recommendations on key outcome measures for organ preservation after (chemo)radiotherapy in patients with rectal cancer. Nat Rev Clin Oncol 2021; 18: 805-816
• 33 Heald RJ, Bussey HJ. Clinical experiences at St. Mark’s Hospital with multiple synchronous cancers of the colon and rectum. Dis Colon Rectum 1975; 18: 6-10
• 34 Pickhardt PJ, Hassan C, Halligan S. et al. Colorectal cancer: CT colonography and colonoscopy for detection--systematic review and meta-analysis. Radiology 2011; 259: 393-405
• 35 Mainenti PP, Romano F, Pizzuti L. et al. Non-invasive diagnostic imaging of colorectal liver metastases. World J Radiol 2015; 7: 157-169
• 36 Westwood M, Joore M, Grutters J. et al. Contrast-enhanced ultrasound using SonoVue® (sulphur hexafluoride microbubbles) compared with contrast-enhanced computed tomography and contrast-enhanced magnetic resonance imaging for the characterisation of focal liver lesions and detection of liver metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 2013; 17: 1-243
• 37 O’Leary MP, Parrish AB, Tom CM. et al. Staging Rectal Cancer: The Utility of Chest Radiograph and Chest Computed Tomography. Am Surg 2016; 82: 1005-1008
• 38 Lazzaron AR, Vieira MV, Damin DC. Should preoperative chest computed tomography be performed in all patients with colorectal cancer?. Colorectal Dis 2015; 17: O184-O190
• 39 Halavaara J, Breuer J, Ayuso C. et al. Liver tumor characterization: comparison between liver-specific gadoxetic acid disodium-enhanced MRI and biphasic CT--a multicenter trial. J Comput Assist Tomogr 2006; 30: 345-354