Imaging Recommendations for Diagnosis, Staging, and Management of Small Bowel and Colorectal Malignancies
CC BY 4.0 · Indian J Med Paediatr Oncol 2023; 44(01): 071-076
DOI: DOI: 10.1055/s-0042-1759713
Abstract
Small bowel malignancies are rare, though colorectal cancers are common. This article reviews the current imaging recommendations for small bowel and colorectal malignancies. Contrast-enhanced computed tomography (CT) is the imaging modality of choice for diagnosis/staging/response evaluation/follow-up of the small bowel and colonic tumors. Magnetic resonance imaging of the pelvis with high-resolution T2-weighted images in sagittal, oblique axial, and coronal planes is the imaging modality of choice for staging/response evaluation of anorectal tumors. CT colonography may be utilized as a tumor screening modality, alternative to colonoscopy.
Publication History
Article published online:
06 March 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
Abstract
Small bowel malignancies are rare, though colorectal cancers are common. This article reviews the current imaging recommendations for small bowel and colorectal malignancies. Contrast-enhanced computed tomography (CT) is the imaging modality of choice for diagnosis/staging/response evaluation/follow-up of the small bowel and colonic tumors. Magnetic resonance imaging of the pelvis with high-resolution T2-weighted images in sagittal, oblique axial, and coronal planes is the imaging modality of choice for staging/response evaluation of anorectal tumors. CT colonography may be utilized as a tumor screening modality, alternative to colonoscopy.
Keywords
bowel malignancies - gastroenterology - general surgery - radiology - recommendationsIntroduction
Small and large bowel tumors are a large heterogeneous group of malignancies with variable presentation and prognosis. We provide a review of various consensus guidelines and imaging recommendations for diagnosis as well as follow-up of bowel malignancies.
Risk Factors and Etiopathogenesis
While most cancers are sporadic, syndromes like familial adenomatous polyposis, Lynch syndrome, and Peutz-Jeghers syndrome have a predilection for gastrointestinal (GI) tumors. Other risk factors include old age, male gender, obesity, inflammatory bowel disease, celiac disease, decreased fiber in diet, alcohol, red or processed meat, smoked food, tobacco, human immunodeficiency virus (HIV) infection, and long-term immunosuppression.[1] [2] Adenocarcinoma is by far the most common tumor, with carcinoid, gastrointestinal stromal tumor (GIST), squamous cancer (anal canal), lymphoma, non-GIST sarcoma, and metastasis being the other potential tumors.[1] [2] The guidelines below pertain predominantly to adenocarcinoma.
Epidemiology and Clinical Presentation
Large bowel tumors are quite common, accounting for approximately 10%-of all cancers in the world.[3] Small bowel tumors are relatively rare, forming less than symbol 2%-of all GI tumors.[1] Small bowel tumors are often clinically silent for long, presenting with vague abdominal pain, nausea, vomiting, melena, and weight loss.[1] Colorectal tumors usually present with altered bowel habits, iron-deficiency anemia (especially right colonic primaries), obstruction, and rectal bleeding. Patients with colorectal cancer usually present between 60 and 80 years, while small bowel tumors present a decade earlier. Patients with signet cell cancers may, however, present in the second to fourth decades of life.[1] [2] [4]
Small Bowel Malignancies
Screening
No imaging study is recommended for screening individuals for small bowel malignancies. Patients with Crohn's disease may undergo regular magnetic resonance imaging/computed tomography (MRI/CT) for evaluating the disease activity status and to look for complications.
Diagnosis and Staging
A single-phase contrast-enhanced CT (CECT) of the thorax, abdomen, and pelvis with oral contrast is the investigation of choice for small bowel tumors ([Table 1]).[1] [5] CT enterography/enteroclysis may be performed if the primary is poorly appreciable with a standard CECT (National Comprehensive Cancer Network [NCCN], category 2A).
Primary tumor |
|
---|---|
Lesion |
● Visible |
● Not visible (i.e., lesions endoscopically resected and subsequently characterized as cancer polyps) |
|
Site |
● Duodenum |
● Jejunum (proximal, distal) |
|
● Ileum (proximal, distal) |
|
● Cecum |
|
● Ascending colon |
|
● Hepatic flexure |
|
● Proximal transverse colon |
|
● Distal transverse colon |
|
● Splenic flexure |
|
● Descending colon |
|
● Sigmoid colon |
|
●Rectosigmoid junction |
|
Type |
● Stenosing |
● Intraluminal polypoidal |
|
● Infiltrating |
|
● Other combinations |
|
Size |
In two dimensions (D1*D2) |
T stage |
T2 |
T3 |
|
T4a |
|
T4b (specify organ/s) |
|
Associated findings |
Bowel obstruction, perforation, ascites, peritoneal thickening, |
Lymph node status |
|
Locoregional |
Yes/no |
If yes: - N1a - N1b - N1c - N2a - N2b Site: |
|
Distant metastases |
|
Distant metastases |
Yes/no If yes: |
- M1a - M1b - M1c |
|
Specify Liver: Yes/no, Number, size, site, relationship with vascular and biliary structures, and liver hilum and other organs Lung: Yes/no, number, site, size |
|
Other organs including nonlocoregional lymph nodes |
|
Final stage (TNM) |
Technical details |
Use of rectal gel for distension—Yes/no |
---|---|
Tumor visible |
Yes/no |
Site of tumor |
Rectum: upper, mid, lower Anal canal |
Distance of lowest tumor margin from anal verge |
____ mm / Cannot be measured |
Distance of lower tumor margin from anorectal junction |
____mm / Cannot be measured |
Anterior peritoneal reflection |
Involved/ uninvolved |
Circumferential tumor location |
Completely encircling / Partial (describe 'o clock position) |
Longitudinal tumor size |
____mm |
Shortest tumor distance from mesorectal fascia/levator ani |
____mm |
Sphincter involvement |
Yes/no |
Adjacent organ involvement |
Yes/no Mention the organ/s involved |
Mesorectal lymph node |
Yes/no Number and size of nodes |
Extramesorectal lymph node spread |
Yes/no Number, site, and size of nodes |
Extramural venous invasion |
Yes/no |
Report distant metastases |
MRI tumor regression grade |
||
---|---|---|
Tumor regression grade 1 |
Complete response |
No residual tumor |
Tumor regression grade 2 |
Good response |
> 75% fibrosis with minimal residual tumor |
Tumor regression grade 3 |
Moderate response |
>50%-fibrosis/mucin with obvious residual intermediate signal intensity tumor |
Tumor regression grade 4 |
Slight response |
significant residual tumor with little fibrosis/ mucin |
Tumor regression grade 5 |
No response |
No interval change in tumor |
References
- Jasti R, Carucci LR, Carucci LR. Small bowel neoplasms: a pictorial review. Radiographics 2020; 40 (04) 1020-1038
- Indian Council of Medical Research Consensus Document for Management of Colorectal Cancer. Accessed November 17, 2022, at: https://main.icmr.nic.in/sites/default/files/guidelines/Colorectal%-20Cancer_0.pdf
- GLOBOCAN. 2020 Accessed November 17, 2022, at: https://gco.iarc.fr/today/data/factsheets/cancers/10_8_9-Colorectum-fact-sheet.pdf
- Colorectal Cancer in India: An Audit from a Tertiary Center in a Low Prevalence Area. Patil PS, Saklani A, Gambhire P, Mehta S, Engineer R, De'Souza A et al. Indian J Surg Oncol 2017; 8: 484-490
- Guidelines Version NCCN. 1.2022 Small bowel adenocarcinoma. Accessed November 17, 2022, at: https://www.nccn.org/professionals/physician_gls/pdf/small_bowel.pdf
- Horvat N, Carlos Tavares Rocha C, Clemente Oliveira B, Petkovska I, Gollub MJ. MRI of rectal cancer: tumor staging, imaging techniques, and management. Radiographics 2019; 39 (02) 367-387
- Moreno C, Kim DH, Bartel TB. et al; Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® colorectal cancer screening. J Am Coll Radiol 2018; 15 (5S): S56-S68
- Fowler KJ, Kaur H, Cash BD. et al; Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® pretreatment staging of colorectal cancer. J Am Coll Radiol 2017; 14 (5S): S234-S244
- Benson AB, Venook AP, Al-Hawary MM. et al. Colon Cancer, Version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2021; 19 (03) 329-359 . Doi: 2
- Benson AB, Venook AP, Al-Hawary MM. et al. NCCN guidelines insights: rectal cancer, Version 6.2020. J Natl Compr Canc Netw 2020; 18 (07) 806-815
- Sirohi B, Shrikhande SV, Perakath B. et al. Indian Council of Medical Research consensus document for the management of colorectal cancer. Indian J Med Paediatr Oncol 2014; 35 (03) 192-196
- Glynne-Jones R, Wyrwicz L, Tiret E. et al; ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28 (suppl_4): iv22-iv40
- Amin MB, Greene FL, Edge SB. et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 2017; 67 (02) 93-99
- Benson AB, Venook AP, Al-Hawary MM. et al. Rectal Cancer, Version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018; 16 (07) 874-901
- Benson AB, Venook AP, Al-Hawary MM. et al. Anal carcinoma, Version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018; 16 (07) 852-871
- Rao S, Guren MG, Khan K. et al; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Anal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up☆ . Ann Oncol 2021; 32 (09) 1087-1100
- Lambregts DMJ,
Bogveradze N, Blomqvist LK. et al. Current controversies
in TNM for the radiological staging of rectal cancer and how to deal with them: results of a global online survey
and multidisciplinary expert consensus. Eur Radiol 2022; 32 (07) 4991-5003
Address for correspondence
Raju SharmaDepartment of Radiodiagnosis and Interventional Radiology, All India Institute of Medical SciencesNew Delhi 110029IndiaEmail: raju152@yahoo.comPublication History
Article published online:
06 March 2023© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
References
- 1 Jasti R, Carucci LR, Carucci LR. Small bowel neoplasms: a pictorial review. Radiographics 2020; 40 (04) 1020-1038
- 2 Indian Council of Medical Research Consensus Document for Management of Colorectal Cancer. Accessed November 17, 2022, at: https://main.icmr.nic.in/sites/default/files/guidelines/Colorectal Cancer_0.pdf
- 3 GLOBOCAN. 2020 Accessed November 17, 2022, at: https://gco.iarc.fr/today/data/factsheets/cancers/10_8_9-Colorectum-fact-sheet.pdf
- 4 Colorectal Cancer in India: An Audit from a Tertiary Center in a Low Prevalence Area. Patil PS, Saklani A, Gambhire P, Mehta S, Engineer R, De'Souza A et al. Indian J Surg Oncol 2017; 8: 484-490
- 5 Guidelines Version NCCN. 1.2022 Small bowel adenocarcinoma. Accessed November 17, 2022, at: https://www.nccn.org/professionals/physician_gls/pdf/small_bowel.pdf
- 6 Horvat N, Carlos Tavares Rocha C, Clemente Oliveira B, Petkovska I, Gollub MJ. MRI of rectal cancer: tumor staging, imaging techniques, and management. Radiographics 2019; 39 (02) 367-387
- 7 Moreno C, Kim DH, Bartel TB. et al; Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® colorectal cancer screening. J Am Coll Radiol 2018; 15 (5S): S56-S68
- 8 Fowler KJ, Kaur H, Cash BD. et al; Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria® pretreatment staging of colorectal cancer. J Am Coll Radiol 2017; 14 (5S): S234-S244
- 9 Benson AB, Venook AP, Al-Hawary MM. et al. Colon Cancer, Version 2.2021, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2021; 19 (03) 329-359 . Doi: 2
- 10 Benson AB, Venook AP, Al-Hawary MM. et al. NCCN guidelines insights: rectal cancer, Version 6.2020. J Natl Compr Canc Netw 2020; 18 (07) 806-815
- 11 Sirohi B, Shrikhande SV, Perakath B. et al. Indian Council of Medical Research consensus document for the management of colorectal cancer. Indian J Med Paediatr Oncol 2014; 35 (03) 192-196
- 12 Glynne-Jones R, Wyrwicz L, Tiret E. et al; ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28 (suppl_4): iv22-iv40
- 13 Amin MB, Greene FL, Edge SB. et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 2017; 67 (02) 93-99
- 14 Benson AB, Venook AP, Al-Hawary MM. et al. Rectal Cancer, Version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018; 16 (07) 874-901
- 15 Benson AB, Venook AP, Al-Hawary MM. et al. Anal carcinoma, Version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2018; 16 (07) 852-871
- 16 Rao S, Guren MG, Khan K. et al; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Anal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up☆ . Ann Oncol 2021; 32 (09) 1087-1100
- 17 Lambregts DMJ, Bogveradze N, Blomqvist LK. et al. Current controversies in TNM for the radiological staging of rectal cancer and how to deal with them: results of a global online survey and multidisciplinary expert consensus. Eur Radiol 2022; 32 (07) 4991-5003