Luận án nghiên cứu diện cắt chu vi bằng cộng hưởng từ và giải phẫu bệnh trong điều trị phẫu thuật ung thư biểu mô trực tràng tt

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY NGUYEN MINH TRONG RESEARCH OF CIRCUMFERENTIAL RESECTION MARGIN BY MAGNETIC RESONANCE AND PATHOLOGY IN SURGICAL TREATMENT[.]

MINISTRY OF EDUCATION

AND TRAINING

MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

NGUYEN MINH TRONG

RESEARCH OF CIRCUMFERENTIAL RESECTION

MARGIN BY MAGNETIC RESONANCE AND

PATHOLOGY IN SURGICAL TREATMENT OF

THE WORK IS COMPLETED AT HANOI MEDICAL UNIVERSITY

Science instructors:

1 Assoc Prof., PhD Nguyen Xuan Hung

2 Assoc Prof., PhD Pham Hoang Ha

Reviewer 1: Assoc Prof., PhD Trieu Trieu Duong

Reviewer 2: Assoc Prof., PhD Nguyen Quoc Dung

Reviewer 3: Assoc Prof., PhD Dang Viet Dung

The dissertation is defended at the Dissertation Assessment Committee of Hanoi Medical University

LIST OF AUTHOR'S PUBLISHED PAPERS RELATED TO

patients VietNam medical journal 2021, N01- July: 35-40

3 Nguyen Minh Trong, Nguyen Xuan Hung, Pham Hoang Ha et

al The early results of radical surgery in treatment of rectal

cancer VietNam journal of Medicine 2021, Vol 62 N05: 16-21

INTRODUCTION

1 Necessary

Rectal cancer is a common malignancy of the gastrointestinal tract, with an increasing trend According to GLOBOCAN 2020, the incidence of colorectal carcinoma was 732,210 cases (accounting for 3.8% of new cancer cases) and 339,022 deaths (accounting for 3.4% of all cancer deaths)

Circumferential resection margin (CRM) in colorectal cancer was first proposed by P Quick (1986) on pathology, determined by measuring the closest distance of tumor, lymph node metastasis to the mesenteric fascia rectal The rate of invasive circumcision is about 7.2-25%

Magnetic resonance with the advantage of better evaluation of soft tissue has been the consensus of researchers and research associations on rectal cancer in assessing the extent of tumor invasion, the degree of lymph node metastasis, the degree of invasion of the circumcision area, the extent of vascular invasion of the rectal wall, Accuracy, sensitivity and specificity of rectal MRI in evaluating wall invasion are 85%, respectively, 87% and 75% In Vietnam, magnetic resonance has been indicated in the assessment of the stage of colorectal cancer before surgery, but currently there is no study that fully evaluates the circumcfrential resection margin by preoperative MRI and compares it with the pathological results after surgery to confirm the relationship in the diagnosis of circumferential resection margin between MRI and pathology in order to reach the goal of choosing appropriate treatment methods in colorectal cancer in order to improve treatment effectiveness and reduce the risk of local recurrence and increased overall survival

time, so we carried out a study on the topic: “Study of circumferential

section by magnetic resonance and pathology in surgical treatment of rectal carcinoma”

2 Objectives

- Determining the value of magnetic resonance in the diagnosis

of wall invasion, lymph node metastasis, invasion of circumferential resection margin (CRM) and disease stage of rectal carcinoma

- Evaluating the results of surgical treatment of rectal carcinoma

in the group of patients with circumferential resection margin by magnetic resonance and pathology

3 Meaning of the study

The results obtained through the study contribute to the specialty

on the characteristics of magnetic resonance imaging, histopathology

in the diagnosis of rectal carcinoma and the results after radical surgery to treat rectal carcinoma

The topic has scientific significance and practical value, contributing to improving the quality of diagnosis and treatment, saving patients’ lives, and improving survival time in patients with rectal carcinoma

4 Structure of thesis

The thesis has 126 pages, including the following parts: Introduction (2 pages), Chapter 1 (Literature of review 41 pages), Chapter 2 (Subjects and methods 19 pages); Chapter 3 (Results 30 pages); Chapter 4 (Discussion) 32 pages; Conclusion 2 pages

The thesis has 43 tables, 9 figures, 26 images and 165 references (28 documents in Vietnamese, 127 documents in English)

CHAPTER 1 LITERATURE OF REVIEW 1.1 Rectal anatomy and rectal circumferential resection margin

1.1.2.2 Some rectal fascia

1.1.2.3 Circumferential resection margin

Circumferential resection margin (CRM) in rectal cancer was determined by measuring the proximal distance of tumor and lymph

node metastasis to the mesenteric fascia, this concept was developed

by P Quick et al (1986), at the University of Leeds, UK Many previous studies have recorded that the circumferential resection margin is positive when this distance is ≤ 1mm and has a worse prognosis than the circumferential resection margin > 1mm

1.1.2.4 Relating to anatomy and surgery in the treatment of rectal carcinoma

* Anatomy of the posterior rectal wall

* Anatomy of the lateral wall of the rectum

1.2 Diagnosis of rectal carcinoma

1.2.1 Clinical, subclinical characteristics

* Tests to detect cancer markers:

1.2.1.3 Magnetic resonance in the diagnosis of rectal cancer:

- Tumor location: determined vertically from bottom to top (lower, middle or upper rectum) and according to the circumferential plane (according to the clock position), as well as length, relationship anterior peritoneal flexion and the distance from the lower border of the tumor to the anal margin to the anorectal junction, then, select the best surgical method Tumor locations were classified as lower third (0–5 cm from anal margin), middle third (>5–10 cm from anal margin) and upper third (>10 – 15 cm from the anal margin)

- Tumor morphology: morphology of the tumor (nodule, ulcer, infiltration or infiltrative ulcer)

Invasive diagnosis in situ (Wall invasion): The accuracy, sensitivity, and specificity of rectal MRI in the evaluation of wall invasion were 85%, 87%, and 75%, respectively

Diagnosis of lymph node metastasis (N): Compared with the accuracy of MRI in diagnosing tumor invasion, the accuracy of MRI

in assessing the degree of lymph node metastasis of rectal carcinoma

is lower There were studies that suggest that lymph nodes measured

on MRI with a size greater than 9 mm had a high specificity in the assessment of lymph node metastasis To evaluate lymph node metastasis in rectal cancer, it is necessary to combine the evaluation

of lymph node size characteristics and malignant morphological features including irregular border image (1), heterogeneous signal intensity (2), shape circle (3) When the lymph node size is <5mm, metastasis is suspected when all 3 morphological features are present, when the lymph node size is from 5 to 9mm, it is considered as suspected lymph node metastasis with 2 malignant morphological features, and for lymph nodes > 9 mm in size, it is always considered

to be suspected of lymph node metastasis

Diagnosis of distant metastases (M): On MRI, distant metastases are graded as follows: M0: no distant metastasis; M1a: distant metastasis to an organ (liver, lung, ovary, non-regional lymph nodes ); M1b: metastasis more than an organ or peritoneal metastasis

Diagnosing the circumferential margin: The circumferential margin, also known as the superior mesorectal fascia is best determined in the cross-sectional plane on magnetic resonance It presents as a low signal layer surrounding the rectum on T2-weighted images The mesentery of the rectum is composed of fatty tissue, blood vessels and lymphatic system, showing high signal in T2W phase of MRI

1.2.2 Pathology:

1.2.2.1 Macroscopic type: ulcer nodule, nodule, infiltration, besides,

ulcerative, ring types

1.2.2.2 Microscopic type: World Health Organization (WHO) 2010

classification of rectal cancer

1.2.3 Stages of rectal cancer:

1.2.3.1 Invasive classification according to Dukes

1.2.3.2 TNM classification

1.2.4 Histopathology of mesorectal fascia and circumferential resection margin

1.3 Research of circumferential resection margin

1.3.1 History and concepts of circumferential resection margin

In 1986, Quirke and colleagues at the University of Leeds - UK,

in a study analyzing 52 surgical specimens for rectal cancer, introduced the concept of lateral resection margin when measuring the interval Tumors, lymph nodes closest to the cutting area ≤ 12mm The results of the analysis showed that the local recurrence rate was 85% in the group of patients with lateral resection and 3% in

the non-invasive group The article was published in the Lancet (November 1986)

1.3.2 Methods of evaluating the circumferential resection margin 1.3.3 The role of circumferential resection margin in the treatment

of rectal carcinoma

In magnetic resonance imaging, the circumferential area can be determined by measuring the shortest distance between the rectal tumor and lymph node metastasis to the Mesorectal Fascia (MRF) MRF (+) when the distance is ≤ 1mm, and there is a risk when this distance is in the range of 1-2mm

1.4 Surgical treatment of rectal cancer

1.4.1 Principles of radical surgery

- Resection of rectum with tumor and extensive mesenteric: for upper rectal cancer, it is at least 5 cm below the tumor, with at least 2

cm for middle and lower rectal cancer and the whole mesentery Cut over the tumor at least 5 cm

- Extensive lymphadenectomy: Dissect the mesenteric lymph nodes up to the base of the superior mesenteric artery or the inferior mesenteric artery and the iliac lymph nodes if there is evidence of metastasis

- Repeat gastrointestinal circulation if indicated to ensure quality

of life for the patient

1.4.2 Radical surgical method

* Total mesenteric resection: This is considered the standard

technique in surgical treatment of rectal cancer, total mesenteric resection for middle and low rectal cancers, and at least 5cm lower mesenteric resection below the tumor for upper rectal cancer is the standard designation

1.4.3 Results of radical surgical treatment

1.4.3.1 Close results after radical surgery

* Anastomic leakage

* Other accidents and complications: Some accidents and complications have been recorded in rectal cancer surgery such as:

vascular damage, ureteral damage, bladder injury, vaginal injury, peritonitis, surgical site infection

1.4.3.2 Distant results after radical surgery

* Anal sphincter dysfunction; Bladder dysfunction; Sexual function results:

* Survival time, recurrence and metastasis after rectal cancer surgery: The ability to diagnose early and surgical treatment techniques as well as adjuvant treatment measures before and after surgery have actively contributed to prolonging the survival time after surgery as well as improving the quality of life of the patients Studies have shown that the survival rate after 3 years, 5 years of patients with rectal cancer undergoing radical surgery has increased significantly, the rate of local recurrence and distant metastasis after surgery has been much reduced

CHAPTER 2 SUBJECTS AND METHODS 2.1 Subjects

Including patients diagnosed with rectal cancer with preoperative MRI scan, radical surgery treatment at Viet Duc Friendship Hospital and post-operative anatomical assessment, from October 2016 to May 2019

2.1.1 Criteria of selection

- The patient was diagnosed with primary rectal carcinoma, determined based on the postoperative pathology results and the tumor location determined by flexible laparoscopy ≤ 15cm from the anal margin

- Preoperative pelvic magnetic resonance imaging, classification

of TNM stage and circumferential resection margin; radical rectal surgery + lymph node dissection and pathological examination, classification of TNM stage and circumferential resection margin

- The patient consented to participate in the study

2.1.2 Criteria of exclusion

- Have no rectal carcinoma or have other cancer from 2 or more locations or distant metastases: liver, bone, lung Incomplete postoperative pathology results, assessment of TNM classification and circumferential resection margin;

- The patient did not consent to participate in the study

2.2 Reaserch method

The study was carried out by a descriptive prospective study All patients were staged by 1.5 Tesla preoperative magnetic resonance and compared with postoperative pathological results

2.2.1 Research indexes

2.2.1.1 General information

- Age (years), sex (male/female)

- Time from clinical symptoms to hospital admission

- Clinical symptoms on admission

- Tumor enhancement properties

Diagnosis of locally invasive (T) staging

Characteristics of lymph node metastasis, degree of lymph node metastasis (N)

Diagnosis of distant metastasis (M)

Diagnosis of rectal carcinoma staging on MRI

Invasive assessment of the CRM of rectal cancer on MRI

2.2.1.3 Research on the pathology of rectal cancer

- Assessing tumor shape

- Evaluation of the upper and lower section

- Evaluation of the size of the rectal cancer

- Assess the degree of invasion in the rectal lumen

- Evaluation of the stage of rectal cancer according to TNM: based on AJCC 7th (American Joint Committee on Cancer) 2010

- Assess the integrity of the mesentery: based on the classification

of Quirke et al (2009), divided into: complete, little integrity and incomplete

- Evaluation of the CRM

- Distance of tumor, lymph node metastasis to the mesorectal fascia, unit is mm

- Evaluation of the extent of vascular invasion of the rectal wall (EMVI: Extramural Vascular Invasion)

- Microscopic assessment of rectal cancer

- Evaluation of the degree of differentiation: divided into: well differentiated, moderately differentiated, little differentiated and undifferentiated

2.2.1.4 Study on results of surgical treatment of rectal cancer

Research indexes on surgical techniques

- Surgical way: laparoscopic or open surgery

- Operation time, unit is minutes

- Surgical methods: Anterior resection, abdominoperineal, Harmann surgery

- Description of injury during surgery: Abdominal fluid; Tumor location; Anal margin distance; tumor size; Invasive assessment; Evaluation of surgical injuries; Evaluation of intraoperative accidents

Evaluation of the early results after surgery:

- Average hospital time, unit is days

- Evaluation of early complications appearing after 30 days of surgery: bleeding, wound infection; anastomotic leakage; anastomotic stenosis; bowel obstruction; and measures to deal with when complications occur

- Assess the integrity of the mesentery in relation to tumor location, incision, surgical method

Evaluation of distant results after surgery:

- Local recurrence; Distant metastasis; Evaluation of digestive disorders: diarrhea, constipation or fecal incontinence Determine the number of shits/day; Assess sexual status

Description of survival time after surgery: Determination of survival time by age group, gender; Determination of overall survival time by disease stage; Determining the survival time according to the degree of tumor invasion, lymph node metastasis, macroscopic type, microscopic type

2.3 Statistically analysis

The study was processed using SPSS 22.0 software

2.4 Research ethics

- The study was conducted after approving the Ethics Committee

in Biomedical Research: established under Decision No ĐHYHN, May 20, 2014 of the Rector of Hanoi Medical University

1722/QD Information related to study participants is kept confidential

- Non-interventional study on patients

- Research results are not for commercial purposes

- Patients voluntarily participate in the study and have the right

to automatically withdraw from the study without any strings attached to the researcher

CHAPTER 3 RESULTS

From October 2016 to May 2019, at Viet Duc Friendship Hospital, there were 109 rectal cancer patients who met the selection criteria to be included in the study with the following results:

3.1 General characteristics

3.1.1 Age, sex

Table 3.1 Distribution of age and sex