Iron oxide enhanced MRI for (re)staging lymph node status in rectal cancer

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R. Stijns, B. Philips, I. Nagtegaal, C. Wauters, F. Polat, J. de Wilt, T. Scheenen 

The presence of lymph node metastases in cancer patients is an important factor determining their prognosis. Definite lymph node staging in rectal cancer is performed by histopathologic examination of resected nodes after total mesorectal excision (TME). However, TME surgery is associated with considerable morbidity and impairment of quality of life (QoL). Because of the impact on QoL, the current paradigm is shifting towards organ preserving treatments. Perhaps the most important factor in determining such a treatment plan is accurate knowledge of the lymph node status. Detectionof metastases in lymph nodes smaller than 5 mm around the rectum is a major challenge. 

New possibilities to accurately diagnose the presence of these small lymph node metastases in a non-invasive way would represent a major breakthrough. One of these new promising techniques is nano-MRI; an MR imaging technique in which ferumoxtran-10, an ultrasmall superparamagnetic iron oxide (USPIO) particle, is used to detect lymph node metastases. It is already known for several different cancer types that the use of USPIO particles leads to higher accuracy rates for detecting malignant lymph nodes. Therefore a technical validation study has recently started in the Radboudumc, Canisius Wilhelmina hospital and Maas hospital Pantein aiming to extend the use of USPIO particles to patients with rectal cancer. For detection of metastases in the small nodes around the rectum, MRI is performed at magnetic field strengths of 3 and even 7 Tesla.  Patients will be enrolled to undergo an additional MRI scan at the time of primary staging or at restaging after preoperative treatment. With these additional MRI scans, we aim to validate the use of ferumoxtran-10 in reliably detecting lymph node metastases in rectal cancer. If the absence of lymph node metastases can be confirmed in this way, we can support the shift towards organ preserving treatments.

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