Subscribe to RSS
![](/products/assets/desktop/img/oa-logo.png)
DOI: 10.4103/0971-3026.155865
Imaging in rectal cancer with emphasis on local staging with MRI
![](https://www.thieme-connect.de/media/10.1055-s-00050590/201502/lookinside/thumbnails/10_4103_0971-3026_155865_148-1.jpg)
Abstract
Imaging in rectal cancer has a vital role in staging disease, and in selecting and optimizing treatment planning. High-resolution MRI (HR-MRI) is the recommended method of first choice for local staging of rectal cancer for both primary staging and for restaging after preoperative chemoradiation (CT-RT). HR-MRI helps decide between upfront surgery and preoperative CT-RT. It provides high accuracy for prediction of circumferential resection margin at surgery, T category, and nodal status in that order. MRI also helps assess resectability after preoperative CT-RT and decide between sphincter saving or more radical surgery. Accurate technique is crucial for obtaining high-resolution images in the appropriate planes for correct staging. The phased array external coil has replaced the endorectal coil that is no longer recommended. Non-fat suppressed 2D T2-weighted (T2W) sequences in orthogonal planes to the tumor are sufficient for primary staging. Contrast-enhanced MRI is considered inappropriate for both primary staging and restaging. Diffusion-weighted sequence may be of value in restaging. Multidetector CT cannot replace MRI in local staging, but has an important role for evaluating distant metastases. Positron emission tomography-computed tomography (PET/CT) has a limited role in the initial staging of rectal cancer and is reserved for cases with resectable metastatic disease before contemplating surgery. This article briefly reviews the comprehensive role of imaging in rectal cancer, describes the role of MRI in local staging in detail, discusses the optimal MRI technique, and provides a synoptic report for both primary staging and restaging after CT-RT in routine practice.
Publication History
Article published online:
30 July 2021
© 2015. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India
-
References
- 1 Beets-Tan RG, Beets GL. Rectal cancer: Review with emphasis on MR imaging. Radiology 2004;232:335-46.
- 2 Sagar PM, Pemberton JH. Surgical management of locally recurrent rectal cancer. Br J Surg 1996;83:293-304.
- 3 Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumor spread and surgical excision. Lancet 1986;2:996-9.
- 4 Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986;1:1479-82.
- 5 Improved survival with preoperative radiotherapy in resectable rectal cancer. Swedish Rectal Cancer Trial. N Engl J Med 1997;336:980-7.
- 6 Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al.; German Rectal Cancer Study Group. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 2004;351:1731-40.
- 7 Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al.; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638-46.
- 8 Brown G, Davies S, Williams GT, Bourne MW, Newcombe RG, Radcliffe AG, et al. Effectiveness of preoperative staging in rectal cancer: Digital rectal examination, endoluminal ultrasound or magnetic resonance imaging? Br J Cancer 2004;91:23-9.
- 9 American Joint Committee on Cancer Staging. 7 th ed. Colon and Rectum Cancer Staging. Available from: https://cancerstaging.org/referencestools/quickreferences/Documents/ColonMedium.pdf. [Last accessed on 2015 Mar 14].
- 10 Beets-Tan RG, Beets GL. Local staging of rectal cancer: A review of imaging. J Magn Reson Imaging 2011;33:1012-9.
- 11 Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G. The use of MR imaging in treatment planning for patients with rectal carcinoma: Have you checked the "DISTANCE"? Radiology 2013;268:330-44.
- 12 Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, et al.; MERCURY Study Group. One millimetre is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer. Br J Surg 2011;98:872-9.
- 13 Smith NJ, Shihab O, Arnaout A, Swift RI, Brown G. MRI for detection of extramural vascular invasion in rectal cancer. AJR Am J Roentgenol 2008;191:1517-22.
- 14 Koh DM, Smith NJ, Swift RI, Brown G. The relationship between MR demonstration of extramural venous invasion and nodal disease in rectal cancer. Clin Med Oncol 2008;2:267-73.
- 15 Bugg WG, Andreou AK, Biswas D, Toms AP, Williams SM. The prognostic significance of MRI-detected extramural venous invasion in rectal carcinoma. Clin Radiol 2014;69:619-23.
- 16 Engelen SM, Maas M, Lahaye MJ, Leijtens JW, van Berlo CL, Jansen RL, et al. Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge. Eur J Cancer 2013;49:2311-20.
- 17 Taylor FG, Quirke P, Heald RJ, Moran BJ, Blomqvist L, Swift IR, et al.; Magnetic Resonance Imaging in Rectal Cancer European Equivalence Study Study Group. Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study. J Clin Oncol 2014;32:34-43.
- 18 Beets-Tan RG, Lambregts DM, Maas M, Bipat S, Barbaro B, Caseiro-Alves F, et al. Magnetic resonance imaging for the clinical management of rectal cancer patients: Recommendations from the 2012 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 2013;23:2522-31.
- 19 Puli SR, Bechtold ML, Reddy JB, Choudhary A, Antillon MR, Brugge WR. How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review. Ann Surg Oncol 2009;16:254-65.
- 20 Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J. Rectal cancer: Local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology 2004;232:773-83.
- 21 Beaumont C, Pandey T, Gaines Fricke R, Laryea J, Jambhekar K. MR evaluation of rectal cancer: Current concepts. Curr Probl Diagn Radiol 2013;42:99-112.
- 22 Harewood GC. Assessment of publication bias in the reporting of EUS performance in staging rectal cancer. Am J Gastroenterol 2005;100:808-16.
- 23 Vliegen R, Dresen R, Beets G, Daniels-Gooszen A, Kessels A, van Engelshoven J, et al. The accuracy of Multi-detector row CT for the assessment of tumor invasion of the mesorectal fascia in primary rectal cancer. Abdom Imaging 2008;33:604-10.
- 24 Maizlin ZV, Brown JA, So G, Brown C, Phang TP, Walker ML, et al. Can CT replace MRI in preoperative assessment of the circumferential resection margin in rectal cancer? Dis Colon Rectum 2010;53:308-14.
- 25 McQueen AS, Scott J. CT staging of colorectal cancer: What do you find in the chest? Clin Radiol 2012;67:352-8.
- 26 Tan KK, Lopes Gde L Jr, Sim R. How uncommon are isolated lung metastases in colorectal cancer? A review from database of 754 patients over 4 years. J Gastrointest Surg 2009;13:642-8.
- 27 Cipe G, Ergul N, Hasbahceci M, Firat D, Bozkurt S, Memmi N, et al. Routine use of positron-emission tomography/computed tomography for staging of primary colorectal cancer: Does it affect clinical management? World J Surg Oncol 2013;11:49.
- 28 NCCN Guidelines. Rectal Cancers Version 3.2014.NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ® ). NCCN.org.
- 29 Kaur H, Choi H, You YN, Rauch GM, Jensen CT, Hou P, et al. MR imaging for preoperative evaluation of primary rectal cancer: Practical considerations. Radiographics 2012;32:389-409.
- 30 Vliegen RF, Beets GL, von Meyenfeldt MF, Kessels AG, Lemaire EE, van Engelshoven JM, et al. Rectal cancer: MR imaging in local staging--is gadolinium-based contrast material helpful? Radiology 2005;234:179-88.
- 31 Jao SY, Yang BY, Weng HH, Yeh CH, Lee LW. Evaluation of gadolinium-enhanced T1-weighted magnetic resonance imaging in the preoperative assessment of local staging in rectal cancer. Colorectal Dis 2010;12:1139-48.
- 32 Puli SR, Bechtold ML, Reddy JB, Choudhary A, Antillon MR. Can endoscopic ultrasound predict early rectal cancers that can be resected endoscopically? A meta-analysis and systematic review. Dig Dis Sci 2010;55:1221-9.
- 33 Al-Sukhni E, Milot L, Fruitman M, Beyene J, Victor JC, Schmocker S, et al. Diagnostic accuracy of MRI for assessment of T category, lymph node metastases, and circumferential resection margin involvement in patients with rectal cancer: A systematic review and meta-analysis. Ann Surg Oncol 2012;19:2212-23.
- 34 Taylor FG, Quirke P, Heald RJ, Moran B, Blomqvist L, Swift I, et al.; MERCURY Study Group. Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: A prospective, multicenter, European study. Ann Surg 2011;253:711-9.
- 35 Al Sukhni E, Milot M, Friutman M, Brown G, Schmocker S, Kennedy E. User′s guide for the Synoptic MRI report for Rectal Cancer. Cancer Care Ontario. Canadian Cancer Society. Available from: https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=133269. [Last accessed on 2014 Jun 13].
- 36 Engelen SM, Beets-Tan RG, Lahaye MJ, Kessels AG, Beets GL. Location of involved mesorectal and extramesorectal lymph nodes in patients with primary rectal cancer: Preoperative assessment with MR imaging. Eur J Surg Oncol 2008;34:776-81.
- 37 Kotanagi H, Fukuoka T, Shibata Y, Yoshioka T, Aizawa O, Saito Y, et al. The size of regional lymph nodes does not correlate with the presence or absence of metastasis in lymph nodes in rectal cancer. J Surg Oncol 1993;54:252-4.
- 38 Wagman R, Minsky BD, Cohen AM, Saltz L, Paty PB, Guillem JG. Conservative management of rectal cancer with local excision and postoperative adjuvant therapy. Int J Radiat Oncol Biol Phys 1999;44:841-6.
- 39 Koh DM, George C, Temple L, Collins DJ, Toomey P, Raja A, et al. Diagnostic accuracy of nodal enhancement pattern of rectal cancer at MRI enhanced with ultrasmall superparamagnetic iron oxide: Findings in pathologically matched mesorectal lymph nodes. AJR Am J Roentgenol 2010;194:W505-13.
- 40 Lahaye MJ, Engelen SM, Kessels AG, de Bruïne AP, von Meyenfeldt MF, van Engelshoven JM, et al. USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: Predictive criteria. Radiology 2008;246:804-11.
- 41 Shihab OC, Taylor F, Bees N, Blake H, Jeyadevan N, Bleehen R, et al.; MERCURY Study Group. Relevance of magnetic resonance imaging-detected pelvic sidewall lymph node involvement in rectal cancer. Br J Surg 2011;98:1798-804.
- 42 Weiser MR, Quah HM, Shia J, Guillem JG, Paty PB, Temple LK, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg 2009;249:236-42.
- 43 Patel UB, Taylor F, Blomqvist L, George C, Evans H, Tekkis P, et al. Magnetic resonance imaging-detected tumor response for locally advanced rectal cancer predicts survival outcomes: MERCURY experience. J Clin Oncol 2011;29:3753-60.
- 44 Kluza E, Rozeboom ED, Maas M, Martens M, Lambregts DM, Slenter J, et al. T2 weighted signal intensity evolution may predict pathological complete response after treatment for rectal cancer. Eur Radiol 2013;23:253-61.
- 45 Hanly AM, Ryan EM, Rogers AC, McNamara DA, Madoff RD, Winter DC; MERRION Study Group. Multicenter evaluation of rectal cancer reimaging pOst neoadjuvant (MERRION) therapy. Ann Surg 2014;259:723-7.
- 46 Memon S, Lynch AC, Akhurst T, Ngan SY, Warrier SK, Michael M, et al. Systematic review of FDG-PET prediction of complete pathological response and survival in rectal cancer. Ann Surg Oncol 2014;21:3598-607.
- 47 Li C, Lan X, Yuan H, Feng H, Xia X, Zhang Y. 18F-FDG PET predicts pathological response to preoperative chemoradiotherapy in patients with primary rectal cancer: A meta-analysis. Ann Nucl Med 2014;28:436-46.
- 48 Heijnen LA, Lambregts DM, Mondal D, Martens MH, Riedl RG, Beets GL, et al. Diffusion-weighted MR imaging in primary rectal cancer staging demonstrates but does not characterise lymph nodes. Eur Radiol 2013;23:3354-60.
- 49 Park MJ, Kim SH, Lee SJ, Jang KM, Rhim H. Locally advanced rectal cancer: Added value of diffusion-weighted MR imaging for predicting tumor clearance of the mesorectal fascia after neoadjuvant chemotherapy and radiation therapy. Radiology 2011;260:771-80.
- 50 Boone D, Taylor SA, Halligan S. Diffusion weighted MRI: Overview and implications for rectal cancer management. Colorectal Dis 2013;15:655-61.
- 51 Sassen S, de Booij M, Sosef M, Berendsen R, Lammering G, Clarijs R, et al. Locally advanced rectal cancer: Is diffusion weighted MRI helpful for the identification of complete responders (ypT0N0) after neoadjuvant chemoradiation therapy? Eur Radiol 2013;23:3440-9.
- 52 Hötker AM, Garcia-Aguilar J, Gollub MJ. Multiparametric MRI of rectal cancer in the assessment of response to therapy: A systematic review. Dis Colon Rectum 2014;57:790-9.
- 53 Alberda WJ, Dassen HP, Dwarkasing RS, Willemssen FE, van der Pool AE, de Wilt JH, et al. Prediction of tumor stage and lymph node involvement with dynamic contrast-enhanced MRI after chemoradiotherapy for locally advanced rectal cancer. Int J Colorectal Dis 2013;28:573-80.
- 54 Heijnen LA, Lambregts DM, Martens MH, Maas M, Bakers FC, Cappendijk VC, et al. Performance of gadofosveset-enhanced MRI for staging rectal cancer nodes: Can the initial promising results be reproduced? Eur Radiol 2014;24:371-9.