A systematic review of the validity of endoscopic ultrasound for rectal carcinoma staging

1. A systematic review of the validity of endoscopic ultrasound for rectal carcinoma staging Class 1: Adília Rafael, Agostinho Cordeiro, Alberto Lourenço, Alexandre Sarmento, Ana Beatriz Noronha, Ana Carolina Afonso, Ana Catarina Gomes, Ana Catarina Pedrosa, Ana Cristina Duque, Ana Isabel Ponte Supervisors: Altamiro da Costa Pereira, MD, PhD;Mário Dinis Ribeiro, MD, PhD Introduction to Medicine; Porto Faculty of Medicine 2006

2. Index 5) Results 5.1) T Staging 5.2) N Staging 6) Conclusion 7) Website 8) Planning 9) Acknowledgements 1) Introduction 2) Objective 3) Material and Methods 3.1) Study design 3.2) Inclusion Criteria 3.3) Exclusion criteria 3.4) Bibliographic research 3.5) Methodological quality 3.6) Data extraction

3. Introduction • Rectal cancer is the cancer with the highest rate of mortality within the Portuguese population. [Pinheiro et al, 2003] • More than 2000 scientific papers published in the literature have demonstrated EUS’s high accuracy for the diagnosis and staging of rectal cancer. [Fusaroli and Caletti, 2005] • Rectal cancer is staged using Tumor-Node-Metastasis (TNM) staging system. [Savides and Master, 2002]

4. Introduction According to the EUS stage, the management of the cancer is different. [Savides and Master, 2002] Savides T, Master S. EUS in rectal cancer. Gastrointestinal Endoscopy, Vol 56, No 4, 2002.

5. Objective • To evaluate the validity and consistency of EUS for rectal carcinoma staging in relation to surgical specimens in identifying the patients as T3/T4 and N+.

6. Material and Methods Study design • Systematic review • The selected articles describe studies designed to evaluate the accuracy of endoscopic ultrasound (EUS) in rectal carcinoma staging. • The accuracy of EUS is evaluated in a sample of patients with rectal carcinoma. • The results of the application of EUS are compared to the surgical specimen (gold standard). Inclusion Criteria

7. Material and Methods Exclusion Criteria The article describes a systematic review. The article uses a different reference standard. The article evaluates the accuracy of EUS in staging of other cancers rather than rectal carcinoma. The article does not allow the construction of a 2x2 table (for EUS and surgical specimen). The article is written in languages other than English, French, Spanish or Portuguese. The full paper is not available on the Internet, in the facilities of the Faculty of Medicine, IPO or in the local libraries.

8. Material and Methods Bibliographic Research: A bibliographic research was carried out in Medline using the following query: (((((((((("sensitivity and specificity"[All Fields] OR "sensitivity and specificity/standards"[All Fields]) OR "specificity"[All Fields]) OR "screening"[All Fields]) OR "false positive"[All Fields]) OR "false negative"[All Fields]) OR "accuracy"[All Fields]) OR (((("predictive value"[All Fields] OR "predictive value of tests"[All Fields]) OR "predictive value of tests/standards"[All Fields]) OR "predictive values"[All Fields]) OR "predictive values of tests"[All Fields])) OR (("reference value"[All Fields] OR "reference values"[All Fields]) OR"reference values/standards"[All Fields])) OR ((((((((((("roc"[All Fields] OR "roc analyses"[All Fields]) OR "roc analysis"[All Fields]) OR "roc and"[All Fields]) OR "roc area"[All Fields]) OR "roc auc"[All Fields]) OR "roc characteristics"[All Fields]) OR "roc curve"[All Fields]) OR "roc curve method"[All Fields]) OR "roc curves"[All Fields]) OR "roc estimated"[All Fields]) OR "roc evaluation"[All Fields])) OR "likelihood ratio"[All Fields]) AND (("Endoscopic Ultrasound" [All Fields] OR "Endosonography"[All Fields]) AND ("Rectal neoplasms"[All Fields] OR "Colorectal neoplasms"[All Fields])) This query was based on a search strategy in PubMed (MEDLINE) for publications about the evaluation of diagnostic accuracy, suggested by a research article: Devillé, W. L. et. al., Conducting systematic reviews of diagnostic studies: didactic guidelines

10. Material and Methods Methodological Quality: Each article was submitted to evaluation by two reviewers, who independently graded them as far as quality was concerned. • Disagreements were solved by consensus or arbitration (by the supervisor). • Methodological quality was evaluated according to the Standard for Reporting of Diagnostic Accuracy (STARD) checklist: Bossuyt, P. M. et. al., Towards Complete and Accurate Reporting of Studies of Diagnostic Accuracy: The STARD Initiative, Annals of Internal Medicine Vol 138 – No1, 7 January 2003

11. Material and Methods STARD checklist

12. Material and Methods Bossuyt, P. M. et. al., Towards Complete and Accurate Reporting of Studies of Diagnostic Accuracy: The STARD Initiative, Annals of Internal Medicine Vol 138 – nº1, 7 January 2003

13. Material and Methods Data extracted Information about the study : location, initial number of participants, final number of participants, including mean age and number of feminine and masculine participants. Results: number of true positives, false positives, true negatives and false positives in TNM staging. Information about the equipment used: type of instrument, brand, number of operators. Quality assessment: presence or absence of the items in STARD checklist.

14. Results Quality (STARD checklist items) Brand of instrument used Final number of participants 164 154 14 70 49 34 63 39 154 26 30 159 80 60 45 86 545 28 31 52 20 18 16 13 16 20 15 16 16 7 14 9 17 18 18 16 17 18 18 16 Olympus Combison Olympus Olympus Olympus B&K B&K Missing value Missing value Missing value Missing value Missing value Olympus B&K Olympus Olympus Missing value Missing value B&K Olympus Article Akasu T, 1997 Sailer M, 1997 Maldjian C, 1998 Nishimori H, 1998 Blomquist L, 1999 Lee P, 1999 Hunerbein M, 1999 Kazuya A, 2000 Akasu T, 2000 Gualdi F, 2000 Hunerbein M, 2000 Akahoshi K, 2001 Kalantzis C, 2002 Starck M, 2002 Scott R, 2002 Tseng Y, 2002 Garcia-Aguilar J, 2002 Fuchsjager M, 2002 Bali C, 2004 Hurlstone P, 2005

15. Results T staging: Specificity (articles ordered by date of publication)

16. Results Sensitivity

17. Results Specificity and Sensitivity (articles ordered by final number of participants in the study)

18. Number of participants>60

19. Results Specificity and Sensitivity (articles ordered by brand of instrument used in the study)

20. Number of participants>60 and using Olympus

21. Results N-staging: Specificity (articles ordered by date of publication)

22. Results Sensitivity

23. Results Specificity and Sensitivity (articles ordered by final number of participants in the study)

24. Number of participants>60

25. Results Specificity and Sensitivity (articles ordered by brand of instrument used in the study)

26. Conclusion T Staging As far as T staging (T1+T2 vs T3+T4), EUS validity results are heterogenous across studies. • However, when more than 60 patients and Olympus instruments are used both high sensitivity = 0.95 and high specificity = 0.87 are found. • The results were very heterogeneous • Although no pooled results can be used, a high specificity was found in studies with more than 60 participants included. N Staging

27. Conclusion Some limitations in our study may be the cause of some heterogeneity Only the articles written in English, French, Spanish and Portuguese were read; The research was performed in a single database - Medline; The articles obtained were collected from IPO, Faculty of Medicine and the Internet, neglecting all other possible sources.

28. Conclusion • EUS is more accurate in defining T stage (wall involvement) than N stage. • It seems that beyond training, further improvement in N staging should be studied: • redefinition of N involvement in EUS • EUS improvement (new instruments)

29. Website

30. Planning

31. Planning

32. Acknowledgements Professor Altamiro da Costa Pereira Professor Mário Dinis Ribeiro