Learning curve of endorectal ultrasonography in preoperative staging of rectal carcinoma

Abstract

Accurate preoperative staging of rectal carcinoma is essential for optimal treatment. This study was designed to evaluate the accuracy and learning curve of endorectal ultrasonography (ERUS) in the preoperative staging of rectal carcinoma. We retrospectively analyzed the records of patients with rectal carcinoma who underwent preoperative ERUS followed by curative surgery at the Shanxi Province Tumor Hospital between January, 2007 and March, 2010. The patients were divided into three groups, namely A, B and C, depending on whether the examination was performed between January and December, 2007, between January and December, 2008 or between January, 2009 and March, 2010, respectively. Five physicians with no prior experience in ERUS performed the examinations. We compared the ERUS staging with the pathological findings using the tumor-node-metastasis (TNM) classification. The accuracy of ERUS in T and N staging after each additional consecutive 20 patients was calculated for physicians D, E and F. A total of 319 patients underwent ERUS prior to surgery. There were 38 patients in group A, 135 in group B and 146 in group C. Two of the five physicians performed only 47 of the 319 examinations, whereas the remaining 272 patients were examined by physicians D (n=162), E (n=64) and F (n=46). The overall accuracy in assessing the extent of rectal wall invasion (T) was 67%, with 16% of the cases overstaged and 17% understaged and the accuracy in assessing nodal involvement (N) was 66%, with 11% of the cases overstaged and 23% understaged. The total T and N staging accuracy of physicians D, E and F was 75 and 72%; 59 and 59%; and 50 and 52%, respectively. For physicians D, E and F, the accuracy of T and N staging after each additional 20 patients was calculated and the curve of the accuracy reached a plateau after physician D completed 80 cases. Therefore, ERUS is a valuable tool for assessing the depth of tumor invasion and it appears that after ~80 cases a physician may be considered able to apply it efficiently.