Background: Optimal management of endometrial disease requires accurate and timely diagnosis followed by effective treatment. Modern outpatient hysteroscopy can be utilized as a first line method for diagnostic procedure. No touch technique (vaginoscopy) has been introduced in an attempt to make the procedure less painful as it includes reduced anesthetic risks and is cost effective. This study aimed to compare the vaginoscopic hysteroscopy and conventional hysteroscopy in context of pain and patient satisfaction. Also, to compare the procedure time, complications and use of anaesthesia associated with both the techniques Methods: This is a hospital based prospective study which will be conducted on 100 women in department of obstetrics and gynaecology, DMC&H, Ludhiana. After taking informed consent patients will be randomised into 2 groups. Group A (n= 50) patients who will be undergoing vaginoscopic hysteroscopy and Group B (n= 50) who will be undergoing standard hysteroscopy. Both groups were compared based on demographic parameters, pain score, time required for procedure completion and need of anesthesia. Results: The mean pain score, duration required for procedure completion and need of anesthesia was less in vaginoscopy group compared to standard hysteroscopy group. Conclusions: The vaginoscopic approach is less painful, better tolerated, quicker to perform therefore, more successful than standard hysteroscopy technique.

e15694 Background: The TNM classification at pathological evaluation determines prognosis following cancer treatment. For rectal cancer patients who undergo neoadjuvant therapy, whether post-treatment (yp)TNM stage confers the same prognostic value as the corresponding pathologic (p)TNM stage is unknown. Current staging systems and management guidelines do not distinguish between pTNM and ypTNM stage. The objective of this study is to compare the prognostic value of ypTNM versus pTNM stage for rectal cancer using a large cancer registry database. Methods: We conducted a retrospective observational cohort study among patients with resected (y)p stage 0-III rectal cancer identified from the National Cancer Data Base (2010-2017). We compared the overall survival (OS) for patients who underwent upfront surgery (pTNM) and neoadjuvant therapy (ypTNM) for each pathological stage. To account for treatment selection bias, we conducted survival analysis stratified by receipt of guideline concordant care. Patients with pathological stage 0 or I disease who underwent upfront surgery for clinical stage II or III and patients with pathological stage II or III disease who underwent upfront surgery and did not receive any postoperative therapy (pT3-4N0) or adjuvant chemotherapy (pN+) were defined has not having received guideline-concordant care. Survival outcomes were analyzed using the Kaplan-Meier method and log-rank test. Hazard ratios (HR) were estimated by univariate and multivariable Cox proportional hazard models. Results: A total of 11,732 of 50,436 (23.3%) patients underwent upfront surgery (pTNM) and 38,704 (76.7%) received neoadjuvant therapy (ypTNM). Among patients who underwent upfront surgery, 78.8% (9,241 of 11,732) received guideline-concordant care (stage 0 -I, upfront surgery; stage II, upfront surgery with postoperative treatment; stage III, upfront surgery with adjuvant chemotherapy). After stratification by receipt of guideline concordant care, OS were similar between pTNM and ypTNM stage for patients with (y)p stage 0-I (HR, 1.05; 95% confidence interval [CI], 0.96-1.15; 5-year OS, 86.9% versus 87.7%), but were significantly worse for patients with ypTNM compared to pTNM in (y)p stage II (HR, 1.50; 95% CI, 1.27-1.77; 5-year OS, 75.6% versus 83.2%) and (y)p stage III (HR, 1.60; 95% CI, 1.46-1.75; 5-year OS, 67.0% versus 78.2%). The multivariable analysis showed that ypTNM stage was associated with worse OS compared to pTNM stage in each stage (HR, 1.18; 95% CI, 1.08-1.30, P < 0.001 in stage 0-I; HR, 1.51; 95% CI, 1.28-1.79, P < 0.001 in stage II; HR, 1.63, 95% CI, 1.49-1.78, P < 0.001 in stage III). Conclusions: Stage for stage, the ypTNM groups are associated with worse survival than the respective pTNM groups, with the survival disparity between pTNM and ypTNM increasing with increasing stage.

MR imaging comprising high-resolution T2-weighted imaging and high b value diffusion-weighted imaging has proven effective in guiding treatment selection and preoperative planning for rectal cancer. In addition to staging, it enables the noninvasive assessment of key bioimaging markers such as extramural vascular invasion, tumor deposits, and the presence and location of mesorectal fascia and anal sphincter involvement. After neoadjuvant therapy, MR imaging offers noninvasive treatment response, complementing endoscopic and digital rectal evaluations. This assessment plays a crucial role in determining the feasibility of organ preservation or watch-and-wait strategy in patients who achieve complete clinical response.

The accurate localization of lateral pelvic nodes is essential for staging and surgical planning in rectal cancer. The objective of this article is to review existing radiologic and surgical definitions of the boundaries of lateral pelvic lymph node compartments on cross-sectional CT/MR images. In addition, we propose a simplified approach to facilitate the application of these boundaries to CT/MR images. We also discuss a few pitfalls in the localization of pelvic nodes in rectal cancer.

Tumor deposits (TDs) have been a contentious element of the tumor node metastasis staging system for colorectal cancer since their introduction in 1997. Classified within the nodal category, their definition has changed repeatedly due to unclear distinctions from lymph node metastases, extramural vascular invasion, and perineural invasion. Despite updates in the tumor node metastasis system eight edition, ambiguity remains, with current criteria relying heavily on pathologist discretion. The fact that TDs are among the most powerful prognostic indicators warrants standardization, based on scientific evidence. A Delphi consensus among expert pathologists confirmed the lack of specificity and reproducibility in the current definition. In response, a new definition was developed, identifying TDs as discrete tumor nodules in pericolic or perirectal fat, distinct from lymph nodes, extramural vascular invasion, or perineural invasion but possibly originating from them. This definition emphasizes the need to report TDs separately when there is unequivocal tumor extension in relation to vessels or nerves. Size and distance from the primary tumor are debated as potential criteria, although they are not part of the proposed definition. The new definition is a first step to incorporate a more robust, biologically relevant definition of TDs into cancer staging.

PURPOSE:To compare image quality and clinical utility of a T2-weighted (T2W) 3-dimensional (3D) fast spin echo (FSE) sequence using deep learning reconstruction (DLR) versus conventional reconstruction for rectal magnetic resonance imaging (MRI). METHODS:The study included 50 patients with rectal cancer who underwent rectal MRI consecutively between July 7, 2020 and January 20, 2021 using a T2W 3D FSE sequence with DLR and conventional reconstruction. Three radiologists reviewed the two sets of images, scoring overall SNR, motion artifacts, and overall image quality on a 3-point scale and indicating clinical preference for DLR or conventional reconstruction based on those three criteria as well as image characterization of bowel wall layer definition, tumor invasion of muscularis propria, residual disease, fibrosis, nodal margin, and extramural venous invasion. RESULTS:Image quality was rated as moderate or good for both DLR and conventional reconstruction for most cases. DLR was preferred over conventional reconstruction in all of the categories except for bowel wall layer definition. CONCLUSION:Both conventional reconstruction and DLR provide acceptable image quality for T2W 3D FSE imaging of rectal cancer. DLR was clinically preferred over conventional reconstruction in almost all categories.

Accurate localization of lymph node metastases to the correct anatomic compartment (i.e. mesorectal, pelvic side-wall or retroperitoneal) impacts staging and may alter management. Mesenteric and fascial layers separating these compartments facilitate localization of these lymph nodes at surgery. However, these surgical/anatomic planes may not be identifiable on pre-surgical CT/MRI.

Background: The identification of tumor deposits (TD) currently plays a limited role in staging for colorectal cancer (CRC) aside from N1c lymph node designation. The objective of this study was to determine the prognostic impact, beyond American Joint Committee on Cancer N1c designation, of TDs among patients with primary CRC. Methods: Patients who had resected stage I-III primary CRC diagnosed between 2010 and 2019 were identified from the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Cancer-specific survival (CSS) stratified by TD status and lymph node (N) status was calculated using the Kaplan-Meier method and multivariable Cox proportional hazards regression analyses. Results: In total, 147,783 patients with primary CRC were identified. TDs were present in 15,444 patients (10.5%). The presence of TDs was significantly associated with adverse tumor characteristics, including advanced pathologic stage, nodal status, and metastasis status. The presence of TDs was associated with worse CSS (hazard ratio [HR], 3.12; 95% confidence interval [CI], 3.02-3.22), as it was for each given N category (e.g., N2a and TD-negative [HR, 2.50; 95% CI, 2.37-2.64] vs. N2a and TD-positive [HR, 3.75; 95% CI, 3.49-4.03]). The presence of multiple TDs was also associated with decreased CSS for each given N category compared with a single TD (e.g. N2a with one TD [HR, 3.09; 95% CI, 2.65-3.61] vs. N2a with two or more TDs [HR, 4.32; 95% CI, 3.87-4.82]). Conclusions: TDs were identified as an independent predictor of a worse outcome in patients with CRC. The presence of TDs confers distinctly different CSS and provides important prognostic information among patients with CRC and warrants further investigation as a unique variable in future iterations of CRC staging.

AIM:As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative-intent resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long-term outcomes following robotic extended resection for colorectal cancer. METHOD:We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short- and long-term outcomes, using the Kaplan-Meier method to analyse overall and recurrence-free survival. RESULTS:Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three-year overall survival was 88% and median progression-free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years. CONCLUSION:Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer.

Rectal MRI provides a detailed depiction of pelvic anatomy; specifically, the relationship of the tumor to key anatomic structures, including the mesorectal fascia, anterior peritoneal reflection, and sphincter complex. However, anatomic inconsistencies, pitfalls, and confusion exist, which can have a strong impact on interpretation and treatment. These areas of confusion include the definition of the rectum itself, specifically differentiation of the rectum from the anal canal and the sigmoid colon, and delineation of the high versus low rectum. Other areas of confusion include the relative locations of the mesorectal fascia and peritoneum and their significance in staging and treatment, the difference between the mesorectal fascia and circumferential resection margin, involvement of the sphincter complex, and evaluation of lateral pelvic lymph nodes. The impact of these anatomic inconsistencies and sources of confusion is significant, given the importance of MRI in depicting the anatomic relationship of the tumor to critical pelvic structures, to triage surgical resection and neoadjuvant chemoradiotherapy with the goal of minimizing local recurrence. Evolving treatment paradigms also place MRI central in management of rectal cancer. (c) RSNA, 2024 center dot radiographics.rsna.org

Rectal MRI is a critical tool in the care of patients with rectal cancer, having established roles for primary staging, restaging, and surveillance. The comprehensive diagnostic and prognostic information provided by MRI helps to optimize treatment decision-making. However, challenges persist in the standardization and interpretation of rectal MRI, particularly in the context of rapidly evolving treatment paradigms, including growing acceptance of nonoperative management. In this AJR Expert Panel Narrative Review, we address recent advances and key areas of contention related to the use of MRI for rectal cancer. Our objectives include discussing concepts regarding anatomic localization of rectal tumors; exploring the evolving rectal cancer treatment paradigm and implications for MRI assessment; reviewing updates and controversies regarding rectal MRI for locoregional staging, restaging, and surveillance; reviewing current rectal MRI acquisition protocols; and highlighting challenges in homogenizing and optimizing acquisition parameters.

In colorectal cancer, the presence of para-aortic lymph nodes (PALN) indicates extraregional disease. Appropriately selecting patients for whom PALN dissection will provide oncologic benefit remains challenging. This study identified factors to predict survival among patients undergoing PALN dissection for colorectal cancer. An institutional database was queried for patients who underwent curative-intent resection of clinically positive PALN for colorectal cancer between 2007 and 2020. Preoperative radiologic images were reviewed, and patients who did and did not have positive PALN on final pathology were compared. Survival analysis was performed to evaluate the impact of pathologically positive PALN on recurrence-free (RFS) and overall survival (OS). Of 74 patients who underwent PALN dissection, 51 had PALN metastasis at the time of primary tumor diagnosis, whereas 23 had metachronous PALN disease. Preoperative chemotherapy ± radiotherapy was given in 60 cases (81.1

Total neoadjuvant therapy (TNT), which includes chemotherapy and radiation prior to surgical resection, has been recently accepted as the new standard of care for patients with locally advanced low and mid rectal cancers. Multiple clinical trials have evaluated this approach in the last several decades and demonstrated improvement in, local control and reduced risk of recurrence. In addition, in the course of these investigations, it has been shown that between a third and a half of patients experience a clinical complete response (cCR) after being treated with the TNT approach, leading to the development of new organ preservation protocol, now known as watch-and-wait (W&W). On this protocol, cCR patients are not referred for surgery after total neoadjuvant treatment. Instead, they remain on close surveillance and, thus, avoid potential complications associated with surgical resection. Multiple clinical trials are ongoing, investigating the long-term outcomes of these new approaches and the development of less toxic and more effective TNT regimens for LARC. Improvements in technology and rectal MRI protocols position radiologists as vital members of multidisciplinary rectal cancer management teams. Rectal MRI has become a critical tool for rectal cancer initial staging, treatment response assessment, and surveillance on W&W protocols. In this review, we summarize the findings of the pivotal clinical trials that contributed to establishing the current treatment paradigms in locally advanced rectal cancer (LARC) management, with the intention of helping radiologists play more effective roles in their multidisciplinary teams.

Background Neoadjuvant immune checkpoint blockade (IO) is emerging as a therapeutic option for patients with deficient mismatch repair (dMMR) colorectal cancer (CRC) given high pathological response rates. The aim of the study was to characterise imaging and endoscopic response to IO.Methods A retrospective analysis of patients with localised dMMR CRC that received at least one cycle of neoadjuvant anti-PD-1 therapy was conducted. Endoscopy, imaging, and pathological outcomes were reviewed to determine response to treatment according to standardised criteria.Results Thirty-eight patients had received IO for the treatment of localised CRC (median eight cycles). Among evaluable cases (n = 31 for endoscopy and n = 34 for imaging), the best endoscopic response was complete response (CR) in 45% of cases, and the best radiographic response was CR in 23% of cases. Imaging CR rate after <= 4 cycles of IO (n = 1) was 6% compared to 44% after >4 IO cycles (n = 7). Among 28 patients with imaging and endoscopy available, a discrepancy in best response was noted in 15 (54%) cases. At a median follow-up of 28.2 months from IO start, 18 patients underwent surgical resection of which 11 (61%) had pathological CR (pCR). Despite pCR or no evidence of progression >= 6 months after completion of IO among non-operatively managed patients, 72% and 42% of patients had non-CR on imaging and endoscopy, respectively.Conclusions Discrepancies between imaging and endoscopy are prevalent, and irregularities identified on these modalities can be identified despite pathological remission. Improved clinical response criteria are warranted.

Rectal adenocarcinoma constitutes about one-third of all colorectal adenocarcinoma cases. Rectal MRI has become mandatory for evaluation of patients newly diagnosed with rectal cancer because it can help accurately stage the disease, impact the choice to give neoadjuvant therapy or proceed with up-front surgery, and even direct surgical dissection planes. Better understanding of neoadjuvant chemoradiotherapy effects on rectal tumors and recognition that up to 30% of patients can have a pathologic complete response have opened the door for the nonsurgical "watch-and-wait" management approach for rectal adenocarcinoma. Candidates for this organ-preserving approach should have no evidence of malignancy on all three components of response assessment after neoadjuvant therapy (ie, digital rectal examination, endoscopy, and rectal MRI). Hence, rectal MRI again has a major role in directing patient management and possibly sparing patients from unnecessary surgical morbidity. In this article, the authors discuss the indications for neoadjuvant therapy in management of patients with rectal adenocarcinoma, describe expected imaging appearances of rectal adenocarcinoma after completion of neoadjuvant therapy, and outline the MRI tumor regression grading system. Since pelvic sidewall lymph node dissection is associated with a high risk of permanent genitourinary dysfunction, it is performed for only selected patients who have radiologic evidence of sidewall lymph node involvement. Therefore, the authors review the relevant lymphatic compartments of the pelvis and describe lymph node criteria for determining locoregional nodal spread. Finally, the authors discuss limitations of rectal MRI, describe several potential interpretation pitfalls after neoadjuvant therapy, and emphasize how these pitfalls may be avoided. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Colon and rectal cancer imaging has traditionally been performed to assess for distant disease (typically lung and liver metastases) and to assess the resectability of the primary tumor. With technological and scientific advances in imaging and the evolution of treatment options, the role of imaging has expanded. Radiologists are now expected to provide a precise description of primary tumor invasion extent, including adjacent organ invasion, involvement of the surgical resection plane, extramural vascular invasion, lymphadenopathy, and response to neoadjuvant treatment, and to monitor for recurrence after clinical complete response.