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基于磁共振的局部进展期直肠癌新辅助治疗后肿瘤退缩分级评分方法应用现状
何宏 陈思宇 胡富碧

Cite this article as: HE H, CHEN S Y, HU F B. Application status of tumor regression grading method after neoadjuvant chemoradiotherapy based on magnetic resonance imaging for locally advanced rectal cancer[J]. Chin J Magn Reson Imaging, 2024, 15(7): 204-209.本文引用格式:何宏, 陈思宇, 胡富碧. 基于磁共振的局部进展期直肠癌新辅助治疗后肿瘤退缩分级评分方法应用现状[J]. 磁共振成像, 2024, 15(7): 204-209. DOI:10.12015/issn.1674-8034.2024.07.034.


[摘要] 随着结直肠癌的发病率和死亡率在全球范围内显著上升,局部进展期直肠癌(locally advanced rectal cancer, LARC)的治疗策略引起了广泛关注。目前,新辅助治疗(neoadjuvant chemoradiotherapy, NCRT)后行全直肠系膜切除术(total mesorectal excision, TME)被推荐为LARC的标准治疗方案。尽管NCRT能显著改善预后,但LARC患者对此治疗响应存在显著差异。因此,准确评估NCRT的疗效对于临床决策和个体化医疗具有重要意义。当前的疗效评估方法包括血清肿瘤标记物、内镜、直肠腔内超声、CT/MRI等,但各有局限。近年来,磁共振肿瘤退缩分级(magnetic resonance tumor regression grade, mrTRG)系统因其无辐射、多方位成像、软组织分辨率高和动态连续观察的优点而受到关注和推荐,因此,本文旨在通过分析最新的国内外研究文献,着重探讨LARC患者NCRT后mrTRG的应用价值及其现状。
[Abstract] As the incidence and mortality rates of colorectal cancer continue to rise globally, the treatment strategies for locally advanced rectal cancer (LARC) have garnered widespread attention. Currently, total mesorectal excision (TME) following neoadjuvant chemoradiotherapy (NCRT) is recommended as the standard treatment protocol for LARC. Although NCRT can significantly improve outcomes, there is notable variability in LARC patient responses to this treatment. Therefore, accurately assessing the efficacy of NCRT is crucial for clinical decision-making and personalized medicine. Current methods for assessing treatment efficacy include serum tumor markers, endoscopy, endorectal ultrasound, and CT/MRI, each with its limitations. In recent years, the magnetic resonance tumor regression grade (mrTRG) has gained attention and recommendation for its advantages of radiation-free, multi-directional imaging, high soft tissue resolution and dynamic continuous observation. Hence, this article aims to analyze the latest domestic and foreign research literature, and focus on the research value and current status of mrTRG after NCRT in LARC patients.
[关键词] 局部进展期直肠癌;新辅助治疗;磁共振成像;肿瘤退缩分级
[Keywords] locally advanced rectal cancer;neoadjuvant chemoradiotherapy;magnetic resonance imaging;tumor regression grading

何宏    陈思宇    胡富碧 *  

成都医学院第一附属医院放射科,成都 610000

通信作者:胡富碧,E-mail:yingxianghu_cmc@163.com

作者贡献声明:胡富碧设计本研究的方案,并对稿件重要内容进行了修改;何宏、陈思宇起草和撰写稿件,并对稿件重要内容进行了修改;全体作者都同意发表最后的修改稿,同意对本研究的所有方面负责,确保本研究的准确性和诚信。


收稿日期:2024-03-20
接受日期:2024-07-09
中图分类号:R445.2  R735.37 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2024.07.034
本文引用格式:何宏, 陈思宇, 胡富碧. 基于磁共振的局部进展期直肠癌新辅助治疗后肿瘤退缩分级评分方法应用现状[J]. 磁共振成像, 2024, 15(7): 204-209. DOI:10.12015/issn.1674-8034.2024.07.034.

0 引言

       近年来,全球和中国的结直肠癌发病率和死亡率显著上升[1, 2],其中大多数患者初次诊断即为局部进展期直肠癌(locally advanced rectal cancer, LARC)[3]。目前,国内外各大权威指南推荐在新辅助治疗(neoadjuvant chemoradiotherapy, NCRT)后行全直肠系膜切除术(total mesorectal excision, TME),作为LARC的标准治疗方案[4, 5]。但由于肿瘤异质性以及个体差异等因素,约15%~27%的患者能实现病理完全缓解(pathological complete response, PCR)[6]。对于完全缓解的患者,推荐等待观察策略,效果及结局接近传统手术,同时可避免手术带来的并发症[7, 8]。对于未完全缓解但有肿瘤退缩的患者,可降低手术难度、提高R0切除率,并可选用不同的手术方式以提高保肛率[9, 10, 11]。因此,准确评估LARC患者NCRT的疗效对于临床决策和个体化医疗具有重要意义。

       术后病理学检查是NCRT评价的金标准,其中肿瘤退缩分级(tumor regression grade, TRG)是其主要内容之一。TRG的历史始于20世纪90年代,最初的TRG系统由MANDARD等[12]于1994年提出并应用于食管癌患者,用于评估术前放化疗的效果。随后,这一方法被DWORAK等[13]应用于直肠癌的疗效评估。目前TRG已被包括国家综合癌症网络(National Comprehensive Cancer Network, NCCN)和美国癌症联合委员会(American Joint Committee on Cancer, AJCC)在内的多个临床实践指南作为评价指标。其中NCCN对TRG的应用尤其明确,NCCN推荐,在患者接受放化疗后,通过病理学检查评估肿瘤反应,将TRG作为影响手术治疗决策、放疗或化疗计划的重要因素[5]。AJCC则在其肿瘤分期系统中嵌入了TRG评分,将TRG与传统的TNM分期联合使用,更全面地评估肿瘤的预后[14]。然而这些评估方法都需要通过检查手术后切除的肿瘤标本来进行,这一过程存在评估时间滞后的问题,无法完全满足临床实时评估的需求。

       目前LARC患者NCRT后的疗效评价标准被推荐为直肠指检、内镜和MRI的组合模式[15],其中内镜和直肠指检主要用于评估腔内病变。MRI则能够显示内镜难以观察到的部位,如直肠系膜筋膜、壁外血管和环周切缘等情况,从而补充内镜和直肠指检的局限性[16]。磁共振肿瘤退缩分级(magnetic resonance tumor regression grade, mrTRG)评分系统是一种源于病理TRG的MRI评估工具,因其无创性评估的优势受到广泛关注。因此,本文旨在结合相关文献,结合图文深入分析mrTRG评分系统,综述其临床意义及研究现状。

1 mrTRG评分系统分类及应用

1.1 基于T2WI序列的mrTRG评分系统研究现状

       2011年,欧洲直肠癌磁共振成像等效性(European Rectal Cancer Magnetic Resonance Imaging Equivalency, MERCURY)研究小组[17]基于DWORAK等提出的病理TRG原理,以肿瘤组织中纤维化间质成分替代程度为依据,发展了基于T2WI序列的五级mrTRG评分系统(表1图1)。该评分系统通过T2WI序列提供高度清晰的组织对比,能够有效评估NCRT后的肿瘤变化,特别适用于观察肿瘤的纤维化和坏死情况。研究表明,基于T2WI的mrTRG评分系统在评估和预测PCR以及区分治疗反应良好与不良方面均具有较好的效能[18, 19]。此外有研究指出mrTRG是LARC患者独立的生存预测指标,可以用于预测其生存结局[20]。这表明,基于T2WI序列的mrTRG评分系统不仅能够可靠地评估NCRT后肿瘤的反应,还能为临床治疗决策提供重要参考。然而,T2WI序列在评估微小残留病灶方面可能存在局限。这为进一步研究提供了方向,即结合其他成像序列,以提高检测敏感度和特异度。

图1  基于T2WI序列的五级mrTRG系统部分评价案例。1A、1D:女,73岁,NCRT前后高分辨率T2WI图像,原肿瘤部位(1A红箭)可见完全纤维成分(1D白箭),为mrTRG 1级,术后病理为AJCC-pTRG 0级。1B、1E:女,74岁,NCRT前后高分辨率T2WI图像,原肿瘤部位(1B红箭)可见大部分纤维成分(1E白箭)以及少量肿瘤成分(1E红箭),为mrTRG 3级,术后病理为AJCC-pTRG 1级。1C、1F:男,56岁,NCRT前后高分辨率T2WI图像,原肿瘤部位(1C红箭)可见少量纤维成分(1F白箭)以及大量肿瘤成分(1F红箭),为mrTRG 4级,术后病理为AJCC-pTRG 2级。mrTRG:磁共振肿瘤退缩分级;NCRT:新辅助治疗;AJCC:美国癌症联合委员会;pTRG:病理肿瘤退缩分级。
Fig. 1  Partial evaluation case of the five-level mrTRG system based on the T2WI sequence. 1A, 1D: Female, 73-year-old, high-resolution T2WI before and after neoadjuvant chemoradiotherapy (NCRT). The original tumor site (red arrow in 1A) shows complete fibrotic components (white arrow in 1D), classified as mrTRG 1. Postoperative pathology is AJCC-pTRG 0. 1B, 1E: Female, 74-year-old, high-resolution T2WI before and after NCRT. The original tumor site (red arrow in 1B) shows mostly fibrotic components (white arrow in 1E) with a small amount of tumor components (red arrow in 1E), classified as mrTRG 3. Postoperative pathology is AJCC-pTRG 1. 1C, 1F: Male, 56-year-old, high-resolution T2WI before and after NCRT. The original tumor site (red arrow in 1C) shows a small amount of fibrotic components (white arrow in 1F) and a large amount of tumor components (red arrow in 1F), classified as mrTRG 4. Postoperative pathology is AJCC-pTRG 2. mrTRG: magnetic resonance tumor regression grade; NCRT: neoadjuvant chemoradiotherapy; AJCC: American Joint Committee on Cancer; pTRG: pathologic tumor regression grade.
表1  基于T2WI序列的mrTRG标准
Tab. 1  The mrTRG criteria based on T2WI sequences

1.2 T2WI联合DWI序列的mrTRG评分系统研究现状

       扩散加权成像(diffusion-weighted imaging, DWI)是一种功能MRI技术,它基于水分子在体内组织中的扩散特性来生成图像。DWI因其能够有效区分残余肿瘤与水肿、纤维化等成分,可以增强LARC患者NCRT后的临床缓解评估能力而被引入分级系统,从而开发出T2WI联合DWI的mrTRG五级评分系统[21, 22, 23]表2图2, 3, 4, 5),其中T2WI序列提供解剖结构信息,DWI序列提供肿瘤细胞密集性信息。研究显示,基于T2WI+DWI序列的mrTRG评分系统在评估完全反应方面比单独使用基于T2WI的评分系统更为准确[24]。此外,LEE等[25]将T2WI联合DWI的五级mrTRG评分系统优化为三级评分系统,将五级系统中的2级和3级合并为新的mrTRG 1级,将4级和5级合并为新的mrTRG 2级。新的三级评分系统如下:mrTRG 0,完全退缩(无明显肿瘤);mrTRG 1,中度退缩(主要纤维化,退缩>50%);mrTRG 2,不良退缩(主要残留肿瘤,退缩≤50%)。结果显示三级mrTRG评分系统的准确性(72.9% vs. 38.1%;P<0.001)和阅片者间一致性(k=0.580 vs. 0.338;P<0.001)均优于原有的基于T2WI序列的5级mrTRG评分系统,且改良三级mrTRG与NCRT术后3年无病生存期独立相关。然而,目前尚缺乏系统性研究对比这三种评分系统的优劣,这需要进一步探讨和验证。

图2  女,67岁,NCRT前(2A~2C)、后(2D~2F)高分辨率T2WI、轴位DWI(b=1000 s/mm²)和ADC图像。原肿瘤部位(红箭)于T2WI序列可见完全纤维成分、DWI未见扩散受限信号(白箭),基于T2WI+DWI的肿瘤退缩分级为mrTRG 1级,术后病理为AJCC-pTRG 0级。
图3  男,50岁,NCRT前(3A~3C)、后(3D~3F)高分辨率T2WI、轴位DWI(b=1000 s/mm²)和ADC图像。原肿瘤部位(红箭)于T2WI序列可见肠壁增厚、呈显著低信号区,DWI图像上局限性扩散受限信号(红箭),其中白箭所示DWI、ADC均为高信号,为穿透效应所致,结合T2WI序列提示黏蛋白成分,该病例基于T2WI+DWI的肿瘤退缩分级为mrTRG 2级,术后病理为AJCC-pTRG 1级。
图4  男,40岁,NCRT前(4A~4C)、后(4D~4F)高分辨率T2WI、轴位DWI(b=1000 s/mm2)和ADC图像。原肿瘤部位(红箭)于T2WI序列可见少量纤维成分(白箭)略多于DWI图像上少许扩散受限信号(红箭),则该病例基于T2WI+DWI的肿瘤退缩分级为mrTRG 3级,术后病理为AJCC-pTRG 1级。
图5  男,54岁,NCRT前(5A~5C)、后(5D~5F)高分辨率T2WI、轴位DWI(b=1000 s/mm2)和ADC图像。原肿瘤部位(红箭)于T2WI、DWI图像上仍然可见大量肿瘤信号(红箭),该病例基于T2WI+DWI的肿瘤退缩分级为mrTRG 5级,术后病理为AJCC-pTRG 3级。NCRT:新辅助治疗;DWI:扩散加权成像;ADC:表观扩散系数;mrTRG:磁共振肿瘤退缩分级;AJCC:美国癌症联合委员会;pTRG:病理肿瘤退缩分级。
Fig. 2  Female, 67-year-old, high-resolution T2WI, axial DWI (b=1000 s/mm2), and ADC images before (2A-2C) and after (2D-2F) NCRT, respectively. The original tumor site (red arrow) currently shows complete fibrotic components on the T2WI sequence and no diffusion restriction signals on DWI (white arrow). Based on the T2WI+DWI sequences, the tumor regression grade is mrTRG 1. Postoperative pathology was AJCC-pTRG 0.
Fig. 3  Male, 50-year-old, high-resolution T2WI, axial DWI (b=1000 s/mm2), and ADC images before and after NCRT, respectively. The original tumor site (red arrow) currently shows bowel wall thickening with a significant hypointense area on the T2WI sequence and localized diffusion restriction signals on the DWI images (red arrow). The high signals on both DWI and ADC images (white arrow) are due to the penetration effect, indicating mucinous components based on the T2WI sequence. The tumor regression grade based on the T2WI+DWI sequences is mrTRG 2. Postoperative pathology is AJCC-pTRG 1.
Fig. 4  Male, 40-year-old, high-resolution T2WI, axial DWI (b=1000 s/mm2), and ADC images before and after NCRT, respectively. The original tumor site (red arrow) currently shows a small amount of fibrotic components (white arrow) on the T2WI sequence, which are slightly more than the limited diffusion restriction signals on the DWI images (red arrow). Based on the T2WI+DWI sequences, the tumor regression grade is mrTRG 3. Postoperative pathology is AJCC-pTRG 1.
Fig. 5  Male, 54-year-old, high-resolution T2WI, axial DWI (b=1000 s/mm2), and ADC images before and after NCRT, respectively. The original tumor site (red arrow) currently shows a large amount of tumor signals on both T2WI and DWI images (red arrow). Based on the T2WI+DWI sequences, the tumor regression grade is mrTRG 5. Postoperative pathology is AJCC-pTRG 3. NCRT: neoadjuvant chemoradiotherapy; DWI: diffusion-weighted imaging; ADC: apparent diffusion coefficient; mrTRG: magnetic resonance tumor regression grade; AJCC: American Joint Committee on Cancer; pTRG: pathologic tumor regression grade.
表2  基于T2WI联合DWI的mrTRG标准
Tab. 2  The mrTRG Criteria Based on Combined T2WI and DWI

1.3 基于DCE-MRI序列的mrTRG评分系统研究现状

       动态对比增强MRI(dynamic contrast-enhanced MRI, DCE-MRI)是一种利用对比剂来增强图像的MRI技术。DCE-MRI的定量参数,如容量转移常数、血管外细胞外空间体积比等在评估肿瘤的血流动力学特性方面发挥重要作用,可能有助于确定对NCRT的反应[5, 26]。然而这些定量参数在实际工作中获取复杂且烦琐,因此,使用DCE-MRI的定性指标有望成为一种简化且实用的替代方法。如GOLLUB等[27]提出了一种新型的5点评分量表,该量表基于残余肿瘤在DCE-MRI中的灌注和廓清特征,将其纳入mrTRG评分系统(表3)。研究结果显示,即使在纳入了DCE-MRI的mrTRG评分系统,其与仅使用传统MRI技术(T2WI和DWI-MRI)相比,两者的受试者工作特征曲线下面积相近(分别为0.66和0.68),表明评分系统中引入DCE-MRI并不能显著提升对治疗反应的诊断效果。POPITA等[28]的研究显示出与之相似的结果。

       综合来看,尽管DCE-MRI在理论上具有显著优势,其定性指标在实际应用中的效果却未能显著超越传统MRI技术。因此,进一步研究和优化DCE-MRI的应用,特别是简化其临床应用流程,仍然是提高LARC患者NCRT疗效评估准确性的重要方向。

表3  纳入DCE-MRI序列的肿瘤退缩分级标准
Tab. 3  The tumor shrinkage grading criteria incorporating DCE-MRI sequences

2 不同mrTRG评价方法比较

2.1 观察者间的一致性

       观察者间一致性是反映评价方法可重复性和可再现性的重要指标之一。由于mrTRG是一个半定性的评分系统,容易受到主观因素的影响,并且NCRT后直肠肿瘤的反应复杂,以及T2WI序列难以准确判断肿瘤残余与水肿、纤维化等问题,导致在多项研究中mrTRG的观察者间一致性的变异性大,其Kappa值波动在0.309~0.650之间[17, 29, 30, 31]。当将DWI纳入评分系统以及将评分系统转化为二分类(退缩良好、退缩不良)时,其观察者间一致性均有所提高[30]

       然而,目前存在的一个关键问题是如何有效地结合T2WI和DWI序列。CHANDRAMOHAN等[32]提出了一种以DWI序列为主的T2WI和DWI组合方法。例如DWI评分为mrTRG 1,而T2WI为mrTRG 1~3,则最终评分取决于DWI,即评为mrTRG 1。结果表明,这种组合方法的观察者间的一致性较单独使用T2WI或DWI得到了显著提高。POPITA等[28]则建议分别在T2WI和DWI上评估肿瘤的缓解程度,并采用两者中的最高分级作为最终的综合评分。研究发现,这种综合评分方法在观察者间一致性方面逊色于单独使用T2WI(k=0.828 vs. 0.876,k=0.544 vs. 0.605)。这可能是因为该方法在结合两种评分时没有充分利用DWI在识别残余肿瘤方面的能力。

       此外,放射科医师的临床经验也直接影响一致性。KHABABI等[31]的研究发现,无论是基于T2WI的五级评分系统还是纳入DWI的改良mrTRG评分系统,经验丰富的放射科医师的一致性均优于低年资放射科医师。另一项研究[33]展示了在对35名放射科医师使用基于T2WI序列的mrTRG量表进行培训后,他们对12名患者的肿瘤退缩分级的能力,并将这些结果与一名中心审核医师评估进行了比较,结果显示,整体具有中等的一致性(k=0.57),在经验丰富的观察者间则具有极好的一致性(k>0.8),分析还揭示了即使是缺乏诊断经验的医师,在接受简短培训后,也能获得良好的mrTRG评价一致性,这表明mrTRG评分系统在临床实践中具有推广和应用的价值。

2.2 诊断效能的比较

       不同的mrTRG评分系统在评估直肠癌患者接受NCRT后的PCR方面,诊断效能存在显著性的差异。即便是采用相同的mrTRG评分系统,在不同机构以及不同的病理诊断标准下,其诊断效能亦存在差异,整体而言,纳入DWI序列可提高对CR的诊断效能(表4)。

表4  不同mrTRG评分系统诊断指标的比较
Tab. 4  Comparison of the diagnostic indicators of different mrTRG scoring systems

3 mrTRG系统与病理的比较

       肿瘤评估系统的准确性通常以其与病理学结果的一致性为金标准来评价。在mrTRG评分系统的应用中,尽管研究显示其在预测治疗反应方面具有良好潜力,但它与病理学结果之间的一致性依然不理想[35, 37, 38]。这种差异可能源于MRI特征、评估层面与实际组织病理学之间的固有差异。同时,作为评估金标准的病理TRG也存在多种评价方法和标本取材变异,以及观察者间一致性存在显著差异[39]。有研究[30]指出,相比于病理TRG,mrTRG一定程度上能更有效地预测总生存期和无病生存期,其在预测患者预后方面的价值超过了病理TRG,这表明mrTRG不必过分追求与病理TRG完全一致,而是应侧重于提高其预测准确性和临床结局的相关性。

4 局限性

       虽然上述研究表明mrTRG评分系统在LARC患者NCRT疗效评估中的价值,但相关研究存在一定的局限性。(1)缺乏统一的mrTRG评分系统以及mrTRG评分标准与PCR的对应关系,不同医师对mrTRG评分系统的认识和使用存在差异,从而导致不同研究结果之间的可比性不足。(2)当前多数研究主要关注mrTRG评分系统与PCR之间的关系,对于近似完全缓解的研究还相对不足。值得注意的是,近似完全缓解的患者通常也具有较好的临床结局[40],但关于近似完全缓解评价的研究较少。(3)多中心、大规模的验证研究尚不足,限制了mrTRG评分系统的广泛应用。

5 小结与展望

       综上发现:(1)基于T2WI序列的mrTRG评分系统在评估和预测PCR方面具有较好效能,结合DWI序列进一步提高了准确性。DCE-MRI在理论上具有优势,其实际效果尚未显著优于传统MRI技术。(2)mrTRG评分系统存在观察者间一致性、诊断效能和与病理结果匹配度等挑战。未来的研究需改进和统一mrTRG评分系统,制订统一的评分标准,并建立与PCR的明确对应关系。同时,应加强对近似完全缓解的研究,改善技术方法,探索更有效的评分策略。此外,开展多中心研究,验证和优化mrTRG评分系统在不同临床场景中的适用性也至关重要。加强放射科医师对该系统的培训,以提高评价的准确性和一致性。这样mrTRG评分系统有望更好地用于LARC患者NCRT疗效评估,为临床治疗决策提供更为可靠的依据,从而提高患者预后和生活质量。

[1]
SUNG H, FERLAY J, SIEGEL R L, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2021, 71(3): 209-249. DOI: 10.3322/caac.21660.
[2]
郑荣寿, 陈茹, 韩冰峰, 等. 2022年中国恶性肿瘤流行情况分析[J]. 中华肿瘤杂志, 2024, 46(3): 221-231. DOI: 10.3760/cma.j.cn112152-20240119-00035.
ZHENG R S, CHEN R, HAN B F, et al. Cancer incidence and mortality in China, 2022[J]. Chin J Oncol, 2024, 46(3): 221-231. DOI: 10.3760/cma.j.cn112152-20240119-00035.
[3]
王锡山. 从中美结直肠癌流行病学特征看结直肠癌早诊早治的重要性[J]. 中华结直肠疾病电子杂志, 2021, 10(1): 26-33. DOI: 10.3877/cma.j.issn.2095-3224.2021.01.004.
WANG X S. Discussion of the importance of early diagnosis and treatment of colorectal cancer from the epidemiological characteristics of colorectal cancer in China and United States of America[J]. Chin J Colorectal Dis Electron Ed, 2021, 10(1): 26-33. DOI: 10.3877/cma.j.issn.2095-3224.2021.01.004.
[4]
彭俊杰, 朱骥, 刘方奇, 等. 中国局部进展期直肠癌诊疗专家共识[J]. 中国癌症杂志, 2017, 27(1): 41-80. DOI: 10.19401/j.cnki.1007-3639.2017.01.008.
PENG J J, ZHU J, LIU F Q, et al. Expert consensus on diagnosis and treatment of locally advanced rectal cancer in China[J]. China Oncol, 2017, 27(1): 41-80. DOI: 10.19401/j.cnki.1007-3639.2017.01.008.
[5]
BENSON A B, VENOOK A P, AL-HAWARY M M, et al. Rectal cancer, version 2.2022, NCCN clinical practice guidelines in oncology[J]. J Natl Compr Canc Netw, 2022, 20(10): 1139-1167. DOI: 10.6004/jnccn.2022.0051.
[6]
MAAS M, NELEMANS P J, VALENTINI V, et al. Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data[J]. Lancet Oncol, 2010, 11(9): 835-844. DOI: 10.1016/S1470-2045(10)70172-8.
[7]
VAN DER VALK M J M, HILLING D E, BASTIAANNET E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study[J]. Lancet, 2018, 391(10139): 2537-2545. DOI: 10.1016/S0140-6736(18)31078-X.
[8]
KARLSSON L, BOCK D, ASPLUND D, et al. Urinary dysfunction in patients with rectal cancer: a prospective cohort study[J]. Colorectal Dis, 2020, 22(1): 18-28. DOI: 10.1111/codi.14784.
[9]
KOH C E, BROWN K G M, STEFFENS D, et al. What constitutes a clear margin in patients with locally recurrent rectal cancer undergoing pelvic exenteration?[J]. Ann Surg, 2022, 275(1): 157-165. DOI: 10.1097/SLA.0000000000003834.
[10]
李干斌, 韩加刚, 王振军, 等. 新辅助放化疗治疗局部进展期直肠癌疗效分析[J]. 中国实用外科杂志, 2021, 41(2): 184-189, 193. DOI: 10.19538/j.cjps.issn1005-2208.2021.02.15.
LI G B, HAN J G, WANG Z J, et al. Efficacy of neoadiuvant chemoradiotherapy for locally advanced rectalcancer: are trospective study[J]. Chin J Pract Surg, 2021, 41(2): 184-189, 193. DOI: 10.19538/j.cjps.issn1005-2208.2021.02.15.
[11]
RULLIER E, VENDRELY V, ASSELINEAU J, et al. Organ preservation with chemoradiotherapy plus local excision for rectal cancer: 5-year results of the GRECCAR 2 randomised trial[J]. Lancet Gastroenterol Hepatol, 2020, 5(5): 465-474. DOI: 10.1016/S2468-1253(19)30410-8.
[12]
MANDARD A M, DALIBARD F, MANDARD J C, et al. Pathologic assessment of tumor regression after preoperative chemoradiotherapy of esophageal carcinoma. Clinicopathologic correlations[J]. Cancer, 1994, 73(11): 2680-2686. DOI: 10.1002/1097-0142(19940601)73:11<2680:aid-cncr2820731105>3.0.co;2-c.
[13]
DWORAK O, KEILHOLZ L, HOFFMANN A. Pathological features of rectal cancer after preoperative radiochemotherapy[J]. Int J Colorectal Dis, 1997, 12(1): 19-23. DOI: 10.1007/s003840050072.
[14]
EDGE S B, COMPTON C C. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM[J]. Ann Surg Oncol, 2010, 17(6): 1471-1474. DOI: 10.1245/s10434-010-0985-4.
[15]
MAAS M, LAMBREGTS D M, NELEMANS P J, et al. Assessment of clinical complete response after chemoradiation for rectal cancer with digital rectal examination, endoscopy, and MRI: selection for organ-saving treatment[J]. Ann Surg Oncol, 2015, 22(12): 3873-3880. DOI: 10.1245/s10434-015-4687-9.
[16]
中华医学会放射学分会医学影像大数据与人工智能工作委员会, 中华医学会放射学分会腹部学组, 中华医学会放射学分会磁共振学组. 结直肠癌CT和MRI标注专家共识(2020)[J]. 中华放射学杂志, 2021, 55(2): 111-116. DOI: 10.3760/cma.j.cn112149-20200706-00894.
Image Big Data Artificial Intelligence Working Committee of Chinese Society of Radiology Chinese Medical Association, Abdominal Group of Chinese Society of Radiology Chinese Medical Association, Magnetic Resonance Imaging Group of Chinese Society of Radiology Chinese Medical Association. Expert consensus on the colorectal cancer annotation of CT and MRI (2020)[J]. Chin J Radiol, 2021, 55(2): 111-116. DOI: 10.3760/cma.j.cn112149-20200706-00894.
[17]
PATEL U B, TAYLOR F, BLOMQVIST L, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: mercury experience[J]. J Clin Oncol, 2011, 29(28): 3753-3760. DOI: 10.1200/JCO.2011.34.9068.
[18]
JANG J K, CHOI S H, PARK S H, et al. MR tumor regression grade for pathological complete response in rectal cancer post neoadjuvant chemoradiotherapy: a systematic review and meta-analysis for accuracy[J]. Eur Radiol, 2020, 30(4): 2312-2323. DOI: 10.1007/s00330-019-06565-2.
[19]
POPIŢA A R, RUSU A, MUNTEAN V, et al. Preoperative MRI accuracy after neoadjuvant chemoradiation for locally advanced rectal cancer[J]. Med Pharm Rep, 2023, 96(3): 258-268. DOI: 10.15386/mpr-2542.
[20]
SCLAFANI F, BROWN G, CUNNINGHAM D, et al. PAN-EX: a pooled analysis of two trials of neoadjuvant chemotherapy followed by chemoradiotherapy in MRI-defined, locally advanced rectal cancer[J]. Ann Oncol, 2016, 27(8): 1557-1565. DOI: 10.1093/annonc/mdw215.
[21]
IANNICELLI E, PIETROPAOLO M D, PILOZZI E, et al. Value of diffusion-weighted MRI and apparent diffusion coefficient measurements for predicting the response of locally advanced rectal cancer to neoadjuvant chemoradiotherapy[J]. Abdom Radiol, 2016, 41(10): 1906-1917. DOI: 10.1007/s00261-016-0805-9.
[22]
LAMBREGTS D M, VANDECAVEYE V, BARBARO B, et al. Diffusion-weighted MRI for selection of complete responders after chemoradiation for locally advanced rectal cancer: a multicenter study[J]. Ann Surg Oncol, 2011, 18(8): 2224-2231. DOI: 10.1245/s10434-011-1607-5.
[23]
SONG I, KIM S H, LEE S J, et al. Value of diffusion-weighted imaging in the detection of viable tumour after neoadjuvant chemoradiation therapy in patients with locally advanced rectal cancer: comparison with T2 weighted and PET/CT imaging[J]. Br J Radiol, 2012, 85(1013): 577-586. DOI: 10.1259/bjr/68424021.
[24]
张晓燕, 李晓婷, 史燕杰, 等. 高分辨率MR T2WI联合DWI评价直肠癌新辅助治疗后病理学完全缓解[J]. 中国介入影像与治疗学, 2017, 14(3): 164-168. DOI: 10.13929/j.1672-8475.201612020.
ZHANG X Y, LI X T, SHI Y J, et al. High resolution MR T2WI combined with DWI in evaluation of pathological complete response after neoadjuvant therapy in rectal cancer[J]. Chin J Interv Imag Ther, 2017, 14(3): 164-168. DOI: 10.13929/j.1672-8475.201612020.
[25]
LEE M A, CHO S H, SEO A N, et al. Modified 3-point MRI-based tumor regression grade incorporating DWI for locally advanced rectal cancer[J]. AJR Am J Roentgenol, 2017, 209(6): 1247-1255. DOI: 10.2214/AJR.16.17242.
[26]
中国医师协会结直肠肿瘤专业委员会诊疗技术专委会, 中华医学会放射学分会腹部学组. 直肠癌MR扫描及结构式报告规范专家共识[J]. 中华放射学杂志, 2021, 55(11): 1121-1127. DOI: 10.3760/cma.j.cn112149-20210518-00490.
Colorectal Cancer Diagnosis and Treatment Technology Professional Committee of Chinese Medical Doctor Association, Abdomen Group Chinese Society of Radiology Chinese Medical Association. Expert consensus on MR examination and structured report of rectal cancer[J]. Chin J Radiol, 2021, 55(11): 1121-1127. DOI: 10.3760/cma.j.cn112149-20210518-00490.
[27]
GOLLUB M J, BLAZIC I, FELDER S, et al. Value of adding dynamic contrast-enhanced MRI visual assessment to conventional MRI and clinical assessment in the diagnosis of complete tumour response to chemoradiotherapy for rectal cancer[J]. Eur Radiol, 2019, 29(3): 1104-1113. DOI: 10.1007/s00330-018-5719-1.
[28]
POPITA A R, LISENCU C, RUSU A, et al. MRI evaluation of complete and near-complete response after neoadjuvant therapy in patients with locally advanced rectal cancer[J/OL]. Diagnostics, 2022, 12(4): 921 [2024-01-05]. https://pubmed.ncbi.nlm.nih.gov/35453969/. DOI: 10.3390/diagnostics12040921.
[29]
GUAN Z, SUN R J, CAO W T, et al. Magnetic resonance imaging tumor response score (mrTRS) predicts therapeutic effect and prognosis of locally advanced rectal cancer after neoadjuvant chemoradiotherapy: a prospective, multi-center study[J]. Radiother Oncol, 2020, 151: 288-295. DOI: 10.1016/j.radonc.2020.08.028.
[30]
YOEN H, PARK H E, KIM S H, et al. Prognostic value of tumor regression grade on MR in rectal cancer: a large-scale, single-center experience[J]. Korean J Radiol, 2020, 21(9): 1065-1076. DOI: 10.3348/kjr.2019.0797.
[31]
El KHABABI N, BEETS-TAN R G H, TISSIER R, et al. Comparison of MRI response evaluation methods in rectal cancer: a multicentre and multireader validation study[J]. Eur Radiol, 2023, 33(6): 4367-4377. DOI: 10.1007/s00330-022-09342-w.
[32]
CHANDRAMOHAN A, SIDDIQI U M, MITTAL R, et al. Diffusion weighted imaging improves diagnostic ability of MRI for determining complete response to neoadjuvant therapy in locally advanced rectal cancer[J/OL]. Eur J Radiol Open, 2020, 7: 100223 [2024-01-05]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044654. DOI: 10.1016/j.ejro.2020.100223.
[33]
SIDDIQUI M R, GORMLY K L, BHODAY J, et al. Interobserver agreement of radiologists assessing the response of rectal cancers to preoperative chemoradiation using the MRI tumour regression grading (mrTRG)[J]. Clin Radiol, 2016, 71(9): 854-862. DOI: 10.1016/j.crad.2016.05.005.
[34]
VAN DEN BROEK J J, VAN DER WOLF F S, LAHAYE M J, et al. Accuracy of MRI in restaging locally advanced rectal cancer after preoperative chemoradiation[J]. Dis Colon Rectum, 2017, 60(3): 274-283. DOI: 10.1097/DCR.0000000000000743.
[35]
SCLAFANI F, BROWN G, CUNNINGHAM D, et al. Comparison between MRI and pathology in the assessment of tumour regression grade in rectal cancer[J]. Br J Cancer, 2017, 117(10): 1478-1485. DOI: 10.1038/bjc.2017.320.
[36]
PANG X L, XIE P Y, YU L, et al. A new magnetic resonance imaging tumour response grading scheme for locally advanced rectal cancer[J]. Br J Cancer, 2022, 127(2): 268-277. DOI: 10.1038/s41416-022-01801-x.
[37]
NIU S Q, CHEN Y, PENG F, et al. The role of MRI after neochemoradiotherapy in predicting pathological tumor regression grade and clinical outcome in patients with locally advanced rectal adenocarcinoma[J/OL]. Front Oncol, 2023, 13: 1118518 [2024-01-05]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10292078. DOI: 10.3389/fonc.2023.1118518.
[38]
ACHILLI P, MAGISTRO C, AZIZ M A ABD EL, et al. Modest agreement between magnetic resonance and pathological tumor regression after neoadjuvant therapy for rectal cancer in the real world[J]. Int J Cancer, 2022, 151(1): 120-127. DOI: 10.1002/ijc.33975.
[39]
钮东峰, 薛卫成. 直肠癌新辅助治疗后病理评估[J]. 中华胃肠外科杂志, 2018, 21(6): 632-636. DOI: 10.3760/cma.j.issn.1671-0274.2018.06.003.
NIU D F, XUE W C. Pathological evaluation after preoperative neoadjuvant treatment in rectal cancer[J]. Chin J Gastrointest Surg, 2018, 21(6): 632-636. DOI: 10.3760/cma.j.issn.1671-0274.2018.06.003.
[40]
CHEN H Y, FENG L L, LI M, et al. College of American pathologists tumor regression grading system for long-term outcome in patients with locally advanced rectal cancer[J/OL]. Oncologist, 2021, 26(5): e780-e793 [2024-01-05]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8100558. DOI: 10.1002/onco.13707.

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