Role of tumor size in the pre-operative management of rectal cancer patients

Abstract

Background: Clinical management of rectal cancer patients relies on pre-operative staging. Studies however continue to report moderate degrees of over/understaging as well as inter-observer variability. The aim of this study was to determine the sensitivity, specificity and accuracy of tumor size for predicting T and N stages in pre-operatively untreated rectal cancers.

Methods: We examined a test cohort of 418 well-documented patients with pre-operatively untreated rectal cancer admitted to the University Hospital of Basel between 1987 and 1996. Classification and regression tree (CART) and logistic regression analysis were carried out to determine the ability of tumor size to discriminate between early (pT1-2) and late (pT3-4) T stages and between node-negative (pN0) and node-positive (pN1-2) patients. Results were validated by an external patient cohort (n = 28).

Results: A tumor diameter threshold of 34 mm was identified from the test cohort resulting in a sensitivity and specificity for late T stage of 76.3%, and 67.4%, respectively and an odds ratio (OR) of 6.67 (95%CI:3.4-12.9). At a threshold value of 29 mm, sensitivity and specificity for node-positive disease were 94% and 15.5%, respectively with an OR of 3.02 (95%CI:1.5-6.1). Applying these threshold values to the validation cohort, sensitivity and specificity for T stage were 73.7% and 77.8% and for N stage 50% and 75%, respectively.

Conclusions: Tumor size at a threshold value of 34 mm is a reproducible predictive factor for late T stage in rectal cancers. Tumor size may help to complement clinical staging and further optimize the pre-operative management of patients with rectal cancer.

Figure 1

Classification of rectal cancer patients (test cohort) into early and late T stages or into node-negative and node-positive disease based on tumor diameter using classification and regression tree analysis (CART). For the classification of patients by T stage, numbers in parentheses describe (the number of patients with early T, late T stage) followed by (percentage of patients with early T and late T stages). For the classification of patients by N stage, numbers in parentheses describe (the number of patients with node-negative, node-positive disease) followed by (percentage of patients with node-negative, node-positive disease).

Figure 2

Kaplan-Meier survival curves showing differences in survival time between patients with (A) early (pT1-2) and late (pT3-4) rectal tumors and with (B) ≤34 mm and >34 mm rectal tumors.