结直肠癌诊疗指南及规范(3)

2.2.3 附录

附录 2.2.3-1：直肠-肛管癌影像学检查的重要参数 直肠癌位置[10] 直肠癌肿瘤分期（T 分期）[10] 自外括约肌下缘连线向上折线测量肿瘤下缘与肛缘间距离 T1：肿瘤侵犯粘膜下层 T2：肿瘤侵犯固有肌层 T3：肿瘤侵透固有肌层并侵犯浆膜下层（浆膜覆盖段）或 侵犯直肠系膜（无浆膜覆盖）或内外括约肌间隙 根据肿瘤侵入直肠系膜部分与固有肌层的垂直距离分 为：T3a （<1mm），T3b （1-5mm ），T3c （5-15mm ）， T3d（>15mm） T4a：肿瘤侵犯脏层腹膜（浆膜覆盖段） T4b：肿瘤侵犯邻近脏器或结构 直肠癌淋巴结分期（N 分期）[11] 推荐使用高分辨率 MRI 或直肠内镜超声；转移性淋巴结 诊断依据：淋巴结短径大于 8mm，形态不规则、边界不 清楚、信号/回声不均匀 直肠癌侵犯壁外血管形成癌栓 （Extramural Vascular Invasion, EMVI）[12] 推荐使用盆腔高分辨率 MRI 判断直肠癌侵出固有肌层后 侵犯周围血管并形成癌栓，即 EMVI。MRI 能从多角度追 踪观察直肠周围血管，根据血管形态不规则、血管流空征 象部分或全部为肿瘤信号所代替诊断 EMVI 阳性 直肠癌环周切缘[7-8] （Circumferential Resection Margin，CRM）影像诊断 推荐使用盆腔高分辨率 MRI 判断肿瘤，转移性淋巴结， 直肠壁外血管侵犯与直肠系膜筋膜（Mesorectal Fascia，MRF），相邻器官及结构的距离小于 1mm，即为 影像诊断 CRM 阳性 下段直肠癌及肛管癌分期[13] LR1：肿瘤限于肠壁内但未侵犯肠壁全层 LR2：肿瘤侵犯肠壁全层但未见侵至内外括约肌间隙 LR3：侵至内外括约肌间间隙或与肛提肌间距离小于 1mm

LR4：肿瘤侵犯外括约肌，或与肛提肌间距离小于 1mm，或侵犯肛提肌，或侵犯周围结构或器官 附录 2.2.3-2：根据 2016 年 ESMO 直肠癌指南，局部进展期直肠癌放化疗前及手术前风险度分层[14]：

1. 超低度风险：T1 sm1 (-2)，N0

2. 低度风险：低位 T1-2；中高位 T3a (b)，N0 (or N1 如果是高位)，MRF 阴性，EMVI 阴 性

3. 中等度风险：低位 T2 期，中高位 T3c 以上，N1-2 期，EMVI 阳性，T4a，但 MRF 阴性

4. 重度风险：T3 且 CRM 阳性，T4a 或 T4b，侧方淋巴结转移。 附录 2.2.3-3：直肠癌新辅助放化疗效果的 MR 影像评价标准

此项工作需要临床研究证据进一步证实。轴位小 FOV 高分辨 T2WI 非抑脂序列为评价 TRG 的主要序列。信号定义：肿瘤为高于直肠肌层但低于粘膜下层的中等信号；粘液为高于粘膜下层的极高信号；纤维为与肌肉相似的低信号或更低信号。根据病理 Mandard 诊断标准得出直肠癌 TRG 的 MRI 诊断标准 16： 1. mrTRG1：无残余肿瘤。

2. mrTRG2：大量纤维，少量残余肿瘤。 3. mrTRG3：纤维/粘液与残余肿瘤各约占 50%。 4. mrTRG4：少量纤维/粘液，大部分为残余肿瘤。 5. mrTRG5：肿瘤未见明确变化。

参考文献：

1.Floriani I, Torri V, Rulli E,et al. Performance of imaging modalities in diagnosis of liver

metastases from colorectal cancer: a systematic review and meta-analysis. Journal of Magnetic Resonance Imaging 2010; 31(1):19-31. 2. Valérie Vilgrain, Maxime Esvan, Maxime Ronot, et al. A meta-analysis of diffusion- weighted and gadoxetic acid-enhanced MR imaging for the detection of liver metastases. Eur Radiol.2016;26(12): 4595-4615.

3. Moulton CA, Gu CS, Law CH, et al. Effect of PET before liver resection on surgical management for colorectal adenocarcinoma metastases: a randomized clinical trial.JAMA.2014;311:1863-1869.

4.Joyce DL, Wahl RL, Patel PV, et al. Preoperative positron emission tomography to evaluate potentially resectable hepatic colorectal metastases. Arch Surg.2006;141:1220-1226; discussion 1227.

5.Pelosi E, Deandreis D. The role of 18F-fluoro-deoxy-glucose positron emission tomography (FDG-PET) in the management of patients with colorectal cancer. Eur J Surg Oncol.2007;33:1-6.

6.Beets-Tan RG, Lambregts DM, Maas M, et al. Magnetic resonance imaging for the clinical management of rectal cancer patients: recommendations from the 2012 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol.2013;23:2522-2531.

7.Taylor FG, 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.

8.Xie H, Zhou X, Zhuo Z, et al. Effectiveness of MRI for the assessment of mesorectal fascia involvement in patients with rectal cancer: a systematic review and meta-analysis. Dig Surg.2014;31:123-134.

9.Bipat S, Glas AS, Slors FJM, et al. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology.2004;232:773-783.

10.Nougaret S1, Reinhold C, Mikhael HW, et al. The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the \Radiology. 2013 Aug;268(2):330-44.

11.Al-Sukhni E,et al. Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and circumferential resection margin involvement in patients with rectal cancer: a systematic review and meta-analysis. Annals of surgical oncology.2012; 19:2212-2223.

12.Chand, M. et al. The prognostic significance of postchemoradiotherapy high-resolution MRI and histopathology detected extramural venous invasion in rectal cancer. Annals of surgery.2015;261:473-479.

13.Battersby NJ,et al. Prospective Validation of a Low Rectal Cancer Magnetic Resonance Imaging Staging System and Development of a Local Recurrence Risk Stratification Model: The MERCURY II Study. Annals of surgery.2016; 263:751-760.

14. Battersby NJ1, Moran B, Yu S, Tekkis P, Brown G. MR imaging for rectal cancer: the role in staging the primary and response to neoadjuvant therapy. Expert Rev Gastroenterol Hepatol. 2014 Aug;8(6):703-19.

15. Glimelius, B., Tiret, E., Cervantes, A., Arnold, D. & Group, E. G. W. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of oncology : 24 Suppl 6, vi81-88, doi:10.1093/ annonc/mdt240 (2013).

16. Patel, U. B. et al. Magnetic resonance imaging-de …… 此处隐藏：4901字，全部文档内容请下载后查看。喜欢就下载吧 ……