Difference between revisions of "MRI of rectal cancer"
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{{Top | {{Top | ||
|author1=[[User:Rhcastilhos|Rodrigo Horstmann Castilhos]] | |author1=[[User:Rhcastilhos|Rodrigo Horstmann Castilhos]] | ||
| − | |author2= | + | |author2=Authors of integrated Creative Commons article<ref name="Beets-TanLambregts2017">{{cite journal|last1=Beets-Tan|first1=Regina G. H.|last2=Lambregts|first2=Doenja M. J.|last3=Maas|first3=Monique|last4=Bipat|first4=Shandra|last5=Barbaro|first5=Brunella|last6=Curvo-Semedo|first6=Luís|last7=Fenlon|first7=Helen M.|last8=Gollub|first8=Marc J.|last9=Gourtsoyianni|first9=Sofia|last10=Halligan|first10=Steve|last11=Hoeffel|first11=Christine|last12=Kim|first12=Seung Ho|last13=Laghi|first13=Andrea|last14=Maier|first14=Andrea|last15=Rafaelsen|first15=Søren R.|last16=Stoker|first16=Jaap|last17=Taylor|first17=Stuart A.|last18=Torkzad|first18=Michael R.|last19=Blomqvist|first19=Lennart|title=Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting|journal=European Radiology|volume=28|issue=4|year=2017|pages=1465–1475|issn=0938-7994|doi=10.1007/s00330-017-5026-2}}</ref> |
}} | }} | ||
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=== Hardware === | === Hardware === | ||
| − | * Requires an external surface coil | + | * Requires an external surface coil<ref name="Beets-TanLambregts2017"/> |
| − | * 1.5T or 3.0T. | + | * 1.5T or 3.0T.<ref name="Beets-TanLambregts2017"/> |
=== Patient preparation === | === Patient preparation === | ||
| − | * Use of an enema is not routinely recommended | + | * Use of an enema is not routinely recommended<ref name="Beets-TanLambregts2017"/> |
| − | '''Spasmolytics (optional)''' | + | '''Spasmolytics (optional)'''<ref name="Beets-TanLambregts2017"/> |
* may be useful to reduce bowel movement artefacts (no consensus: 57 % recommended/mandatory) | * may be useful to reduce bowel movement artefacts (no consensus: 57 % recommended/mandatory) | ||
* Can be benefical for upper rectal tumors and when imaging is performed at 3.0T (bowel movement artifacts are most prevalent) | * Can be benefical for upper rectal tumors and when imaging is performed at 3.0T (bowel movement artifacts are most prevalent) | ||
| − | '''Endorectal filling (optional)''' | + | '''Endorectal filling (optional)'''<ref name="Beets-TanLambregts2017"/> |
* Not routinely advised (no consensus: 71 % not recommended) | * Not routinely advised (no consensus: 71 % not recommended) | ||
| Line 31: | Line 31: | ||
=== Sequences and sequence angulation === | === Sequences and sequence angulation === | ||
| − | '''Sequences''' | + | '''Sequences'''<ref name="Beets-TanLambregts2017"/> |
* A routine protocol should (at least) include: | * A routine protocol should (at least) include: | ||
| Line 43: | Line 43: | ||
'''Sequence angulation''' | '''Sequence angulation''' | ||
| − | All tumours: | + | All tumours:<ref name="Beets-TanLambregts2017"/> |
* Transverse sequences: perpedicular to the rectal tumour axis | * Transverse sequences: perpedicular to the rectal tumour axis | ||
* Coronal sequences: parallel to the rectal tumour axis | * Coronal sequences: parallel to the rectal tumour axis | ||
| − | Distal tumours: | + | Distal tumours:<ref name="Beets-TanLambregts2017"/> |
* Include coronal sequence parallel to the anal canal to assess the relation between tumour and anal sphincter | * Include coronal sequence parallel to the anal canal to assess the relation between tumour and anal sphincter | ||
| Line 61: | Line 61: | ||
==== Morphology ==== | ==== Morphology ==== | ||
| − | Morphology | + | Morphology<ref name="Beets-TanLambregts2017"/> |
* Solid - polypoid | * Solid - polypoid | ||
| Line 67: | Line 67: | ||
* Mucinous | * Mucinous | ||
| − | Circunferential location within the rectal wall | + | Circunferential location within the rectal wall<ref name="Beets-TanLambregts2017"/> |
* e.g. from X to X o'clock | * e.g. from X to X o'clock | ||
| Line 74: | Line 74: | ||
==== Distance from anorectal junction ==== | ==== Distance from anorectal junction ==== | ||
| − | * Distance from the anorectal junction to the lower pole of the tumour | + | * Distance from the anorectal junction to the lower pole of the tumour<ref name="Beets-TanLambregts2017"/> |
==== Tumour length ==== | ==== Tumour length ==== | ||
| − | + | There is agreement that ‘some measure of tumour size’ | |
should be reported, there was no clear consensus on a specific metric, i.e. whether this should be one-dimensional, threedimensional or a volume measurement, and if and how after CRT an estimation of the tumour volume reduction should be provided. There is no solid evidence that favours one over | should be reported, there was no clear consensus on a specific metric, i.e. whether this should be one-dimensional, threedimensional or a volume measurement, and if and how after CRT an estimation of the tumour volume reduction should be provided. There is no solid evidence that favours one over | ||
| − | another, although some authors have suggested that, specifically for assessment of chemoradiotherapeutic response, whole volume measurements may be preferable. The panel acknowledges that several options exist but from a practical point of view decided to include tumour length as the main metric in the structured report template in Fig. 1, as this was deemed to be most commonly used and more practically applicable than other metrics, with good reported measurement reproducibility. | + | another, although some authors have suggested that, specifically for assessment of chemoradiotherapeutic response, whole volume measurements may be preferable. The panel acknowledges that several options exist but from a practical point of view decided to include tumour length as the main metric in the structured report template in Fig. 1, as this was deemed to be most commonly used and more practically applicable than other metrics, with good reported measurement reproducibility.<ref name="Beets-TanLambregts2017"/> |
==== T-stage ==== | ==== T-stage ==== | ||
| − | * MRI doesn't differentiate T1 from T2 | + | * MRI doesn't differentiate T1 from T2<ref name="Beets-TanLambregts2017"/> |
| − | *'''T1-T2: limited to intestinal wall''' | + | *'''T1-T2: limited to intestinal wall'''<ref name="Beets-TanLambregts2017"/> |
| − | *'''T3: extramural growth''' (including growth into the internal anal sphincter muscle) | + | *'''T3: extramural growth''' (including growth into the internal anal sphincter muscle)<ref name="Beets-TanLambregts2017"/> |
| − | ** '''T3a or T3b: ≤5 mm extramural growth''' | + | ** '''T3a or T3b: ≤5 mm extramural growth'''<ref name="Beets-TanLambregts2017"/> |
| − | ** '''T3c or T3d: >5 mm extramural growth''' | + | ** '''T3c or T3d: >5 mm extramural growth'''<ref name="Beets-TanLambregts2017"/> |
| − | * '''T4''' | + | * '''T4'''<ref name="Beets-TanLambregts2017"/> |
**T4a: Invasion of peritoneal reflection | **T4a: Invasion of peritoneal reflection | ||
**T4b: Invasion of surrounding organs | **T4b: Invasion of surrounding organs | ||
| − | Observations: | + | Observations:<ref name="Beets-TanLambregts2017"/> |
* Stranding into mesorectal fat = equivocal sign; may indicate either a T2 or T3 tumour | * Stranding into mesorectal fat = equivocal sign; may indicate either a T2 or T3 tumour | ||
| Line 99: | Line 99: | ||
==== Sphincter invasion ==== | ==== Sphincter invasion ==== | ||
| − | This information is relevant to surgical approach | + | This information is relevant to surgical approach<ref name="Beets-TanLambregts2017"/> |
| − | |||
| − | Depth of invasion | + | For low tumours with sphincter invasion, describe:<ref name="Beets-TanLambregts2017"/> |
| + | |||
| + | Depth of invasion<ref name="Beets-TanLambregts2017"/> | ||
* invades only the internal sphincter muscle (T3) | * invades only the internal sphincter muscle (T3) | ||
| Line 108: | Line 109: | ||
* also involves the external sphincter | * also involves the external sphincter | ||
| − | Height of invasion | + | Height of invasion<ref name="Beets-TanLambregts2017"/> |
* involves only the proximal 1/3 of the complex/anal canal | * involves only the proximal 1/3 of the complex/anal canal | ||
| Line 117: | Line 118: | ||
=== Mesorectal fascia (and peritoneal) involvement === | === Mesorectal fascia (and peritoneal) involvement === | ||
| − | * Shortest distance betwenn tumour and MRF | + | * Shortest distance betwenn tumour and MRF<ref name="Beets-TanLambregts2017"/> |
** Free (>2 mm) | ** Free (>2 mm) | ||
** Threatened/involved (≤2 mm) | ** Threatened/involved (≤2 mm) | ||
| − | *Location of the shortest distance between tumour and MRF | + | *Location of the shortest distance between tumour and MRF<ref name="Beets-TanLambregts2017"/> |
| − | * Tumour location in relation to anterior peritoneal reflection | + | * Tumour location in relation to anterior peritoneal reflection<ref name="Beets-TanLambregts2017"/> |
** below: MRF invasion | ** below: MRF invasion | ||
** above: when on anterior side = at risk for peritoneal invasion (rather than MRF invasion) | ** above: when on anterior side = at risk for peritoneal invasion (rather than MRF invasion) | ||
| − | Observations: | + | Observations:<ref name="Beets-TanLambregts2017"/> |
* The anterior peritoneal reflection is a landmark that is usually recognised easily on MRI and separates the intra- and extra-peritoneal portions of the mesorectal compartment. Above the anterior peritoneal reflection, the mesorectal compartment is no longer enveloped by the mesorectal fascia on its anterior aspect. As such, anterior mesorectal fascia involvement should only be reported when below the level of the anterior peritoneal reflection. | * The anterior peritoneal reflection is a landmark that is usually recognised easily on MRI and separates the intra- and extra-peritoneal portions of the mesorectal compartment. Above the anterior peritoneal reflection, the mesorectal compartment is no longer enveloped by the mesorectal fascia on its anterior aspect. As such, anterior mesorectal fascia involvement should only be reported when below the level of the anterior peritoneal reflection. | ||
| Line 138: | Line 139: | ||
=== Lymph nodes and tumour deposits === | === Lymph nodes and tumour deposits === | ||
| − | * Important risk factor for local recurrence | + | * Important risk factor for local recurrence<ref name="Beets-TanLambregts2017"/> |
| − | '''Morphologically suspicious characteristics''' | + | '''Morphologically suspicious characteristics'''<ref name="Beets-TanLambregts2017"/> |
* Round shape | * Round shape | ||
| Line 146: | Line 147: | ||
* Heterogeneous signal | * Heterogeneous signal | ||
| − | '''Malignant node criteria''' | + | '''Malignant node criteria'''<ref name="Beets-TanLambregts2017"/> |
* Short axis diameter ≥9 mm | * Short axis diameter ≥9 mm | ||
| Line 155: | Line 156: | ||
=== Extramural vascular invasion (EMVI) === | === Extramural vascular invasion (EMVI) === | ||
| − | * Assessment of extramural vascular (or venous) invasion (EMVI) should be reported routinely, both for primary staging as well as for restaging after CRT. | + | * Assessment of extramural vascular (or venous) invasion (EMVI) should be reported routinely, both for primary staging as well as for restaging after CRT.<ref name="Beets-TanLambregts2017"/> |
| − | * EMVI is an important prognostic staging factor | + | * EMVI is an important prognostic staging factor<ref name="Beets-TanLambregts2017"/> |
== Restaging after neoadjuvant treatment == | == Restaging after neoadjuvant treatment == | ||
| − | * Structured reporting is recommended | + | * Structured reporting is recommended<ref name="Beets-TanLambregts2017"/> |
| − | * When considering organ preservation (watchful waiting) after CRT, MRI findings should be correlated with clinical examination (endoscopy / digital rectal examination) | + | * When considering organ preservation (watchful waiting) after CRT, MRI findings should be correlated with clinical examination (endoscopy / digital rectal examination)<ref name="Beets-TanLambregts2017"/> |
=== Local tumour status === | === Local tumour status === | ||
| − | T2W | + | T2W<ref name="Beets-TanLambregts2017"/> |
* '''No residual tumour mass''' | * '''No residual tumour mass''' | ||
| Line 176: | Line 177: | ||
**yT4, based on growth into: | **yT4, based on growth into: | ||
| − | * Distance from the anorectal junction to the lower pole of the tumour (in cm) | + | * Distance from the anorectal junction to the lower pole of the tumour (in cm)<ref name="Beets-TanLambregts2017"/> |
| − | * Tumour length (in cm) | + | * Tumour length (in cm)<ref name="Beets-TanLambregts2017"/> |
| − | *Sphincter invasion | + | *Sphincter invasion<ref name="Beets-TanLambregts2017"/> |
| − | For low tumours with sphincter invasion, describe: | + | For low tumours with sphincter invasion, describe:<ref name="Beets-TanLambregts2017"/> |
| − | Depth of invasion | + | Depth of invasion<ref name="Beets-TanLambregts2017"/> |
* invades only the internal sphincter muscle | * invades only the internal sphincter muscle | ||
| Line 189: | Line 190: | ||
* also involves the external sphincter | * also involves the external sphincter | ||
| − | Height of invasion | + | Height of invasion<ref name="Beets-TanLambregts2017"/> |
* involves only the proximal 1/3 of the complex/anal canal | * involves only the proximal 1/3 of the complex/anal canal | ||
| Line 198: | Line 199: | ||
=== Mesorectal fascia (and peritoneal) involvement === | === Mesorectal fascia (and peritoneal) involvement === | ||
| − | * If a fatpad re-appears between the tumour and MRF after CRT, the MRF should be considered uninvolved/cleared. | + | * If a fatpad re-appears between the tumour and MRF after CRT, the MRF should be considered uninvolved/cleared.<ref name="Beets-TanLambregts2017"/> |
| − | * Persistent stranding of tumour into the MRF should be considered an equivocal sign that may or may not indicate persistent MRF involvement | + | * Persistent stranding of tumour into the MRF should be considered an equivocal sign that may or may not indicate persistent MRF involvement<ref name="Beets-TanLambregts2017"/> |
=== Lymph nodes and tumour deposits === | === Lymph nodes and tumour deposits === | ||
| − | Restaging after long course neoadjuvant treatment + downstaging interval | + | Restaging after long course neoadjuvant treatment + downstaging interval<ref name="Beets-TanLambregts2017"/> |
* Benign nodes: Short axis diameter <5 mm | * Benign nodes: Short axis diameter <5 mm | ||
| Line 214: | Line 215: | ||
{{Bottom}} | {{Bottom}} | ||
| − | |||
| − | |||
| − | |||
| − | |||
[[Category:MRI]] | [[Category:MRI]] | ||
[[Category:Rectum]] | [[Category:Rectum]] | ||
Revision as of 19:57, 18 July 2019
Authors:
Rodrigo Horstmann Castilhos; Authors of integrated Creative Commons article[1] [notes 1]
This article is a practical summary of the Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) to Magnetic resonance imaging for clinical management of rectal cancer.
Contents
Planning
Choice of modality
- MRI of rectal cancer is generally mandatory for both primary staging and restaging of a known rectal cancer.[1]
- Endorectal ultrasound (EUS) is indicated for:[1]
- Staging for early tumours considered for local excision
- Superior diagnostic performance for differentiating T1 from T2 tumors
Hardware
Patient preparation
- Use of an enema is not routinely recommended[1]
Spasmolytics (optional)[1]
- may be useful to reduce bowel movement artefacts (no consensus: 57 % recommended/mandatory)
- Can be benefical for upper rectal tumors and when imaging is performed at 3.0T (bowel movement artifacts are most prevalent)
Endorectal filling (optional)[1]
- Not routinely advised (no consensus: 71 % not recommended)
- ~60 ml of gel (higher volumes compress perirectal tissues significantly)
- Reduces susceptibility artefacts related to luminal gas on DWI.
- Should not be used routinely: rectal wall distension may interfere with interpretation of the distance between the tumour and the mesorectal fascia, and high T2 signal of the gel may cause T2 shine through effects on DWI.
Sequences and sequence angulation
Sequences[1]
- A routine protocol should (at least) include:
- 2D T2W sequences in 3 planes
- DWI sequence (at least a high b-value of ≥800)
- DWI and ADC maps should be assessed visually (not quantitatively)
- DWI is recommended for restaging of the yT-stage
- FS, T1W (non-enhanced and contrast-enhanced) and DCE sequences are not routinely recommended
- Slice thickness ≤3 mm (axial and coronal T2W)
Sequence angulation
All tumours:[1]
- Transverse sequences: perpedicular to the rectal tumour axis
- Coronal sequences: parallel to the rectal tumour axis
Distal tumours:[1]
- Include coronal sequence parallel to the anal canal to assess the relation between tumour and anal sphincter
Structured reporting
Structured reporting is recommended and should include the items described in the report template of ESGAR.
Primary staging
Local tumour status
Morphology
Morphology[1]
- Solid - polypoid
- Solid - (semi-)annular
- Mucinous
Circunferential location within the rectal wall[1]
- e.g. from X to X o'clock
- Should routinely be reported
Distance from anorectal junction
- Distance from the anorectal junction to the lower pole of the tumour[1]
Tumour length
There is agreement that ‘some measure of tumour size’ should be reported, there was no clear consensus on a specific metric, i.e. whether this should be one-dimensional, threedimensional or a volume measurement, and if and how after CRT an estimation of the tumour volume reduction should be provided. There is no solid evidence that favours one over another, although some authors have suggested that, specifically for assessment of chemoradiotherapeutic response, whole volume measurements may be preferable. The panel acknowledges that several options exist but from a practical point of view decided to include tumour length as the main metric in the structured report template in Fig. 1, as this was deemed to be most commonly used and more practically applicable than other metrics, with good reported measurement reproducibility.[1]
T-stage
- MRI doesn't differentiate T1 from T2[1]
- T1-T2: limited to intestinal wall[1]
- T3: extramural growth (including growth into the internal anal sphincter muscle)[1]
- T4[1]
- T4a: Invasion of peritoneal reflection
- T4b: Invasion of surrounding organs
Observations:[1]
- Stranding into mesorectal fat = equivocal sign; may indicate either a T2 or T3 tumour
- Invasion of the pelvic floor or pelvic side wall muscles = T4
- Growth into the internal anal sphincter muscle = T3
Sphincter invasion
This information is relevant to surgical approach[1]
For low tumours with sphincter invasion, describe:[1]
Depth of invasion[1]
- invades only the internal sphincter muscle (T3)
- also involves the intersphincteric plane
- also involves the external sphincter
Height of invasion[1]
- involves only the proximal 1/3 of the complex/anal canal
- also involves the middle 1/3 of the complex/anal canal
- also involves the lower 1/3 of the complex/anal canal
- involves pelvic floor (levator)
Mesorectal fascia (and peritoneal) involvement
- Shortest distance betwenn tumour and MRF[1]
- Free (>2 mm)
- Threatened/involved (≤2 mm)
- Location of the shortest distance between tumour and MRF[1]
- Tumour location in relation to anterior peritoneal reflection[1]
- below: MRF invasion
- above: when on anterior side = at risk for peritoneal invasion (rather than MRF invasion)
Observations:[1]
- The anterior peritoneal reflection is a landmark that is usually recognised easily on MRI and separates the intra- and extra-peritoneal portions of the mesorectal compartment. Above the anterior peritoneal reflection, the mesorectal compartment is no longer enveloped by the mesorectal fascia on its anterior aspect. As such, anterior mesorectal fascia involvement should only be reported when below the level of the anterior peritoneal reflection.
- Mesorectal fascia involvement:
- Shortest distance between tumour and MRF
- Free: >2 mm
- Threatened: 1.1-2 mm
- Involved (=T3): ≤1 mm or stranding into the MRF
- Shortest distance between tumour and MRF
Lymph nodes and tumour deposits
- Important risk factor for local recurrence[1]
Morphologically suspicious characteristics[1]
- Round shape
- Irregular border
- Heterogeneous signal
Malignant node criteria[1]
- Short axis diameter ≥9 mm
- Short axis diameter 5-8 mm + ≥2 morphologically suspicious characteristics
- Short axis diameter <5 mm + 3 morphologically suspicious characteristics
- Mucinous lymph node (of any size)
Extramural vascular invasion (EMVI)
- Assessment of extramural vascular (or venous) invasion (EMVI) should be reported routinely, both for primary staging as well as for restaging after CRT.[1]
- EMVI is an important prognostic staging factor[1]
Restaging after neoadjuvant treatment
- Structured reporting is recommended[1]
- When considering organ preservation (watchful waiting) after CRT, MRI findings should be correlated with clinical examination (endoscopy / digital rectal examination)[1]
Local tumour status
T2W[1]
- No residual tumour mass
- Complete response: a normalised, two-layered rectal wall
- Complete or near-complete response: a completely hypointense residue (fibrotic wall thickening) without clear residual isointense mass
- Residual tumour mass (and/or focal high sinal on DWI)
- yT-stage: yT1-2
- yT3
- yT3a or yT3b (≤5 mm extramural growth)
- yT3c or yT3d (>5 mm extramural growth)
- yT4, based on growth into:
- Distance from the anorectal junction to the lower pole of the tumour (in cm)[1]
- Tumour length (in cm)[1]
- Sphincter invasion[1]
For low tumours with sphincter invasion, describe:[1]
Depth of invasion[1]
- invades only the internal sphincter muscle
- also involves the intersphincteric plane
- also involves the external sphincter
Height of invasion[1]
- involves only the proximal 1/3 of the complex/anal canal
- also involves the middle 1/3 of the complex/anal canal
- also involves the lower 1/3 of the complex/anal canal
- involves pelvic floor (levator)
Mesorectal fascia (and peritoneal) involvement
- If a fatpad re-appears between the tumour and MRF after CRT, the MRF should be considered uninvolved/cleared.[1]
- Persistent stranding of tumour into the MRF should be considered an equivocal sign that may or may not indicate persistent MRF involvement[1]
Lymph nodes and tumour deposits
Restaging after long course neoadjuvant treatment + downstaging interval[1]
- Benign nodes: Short axis diameter <5 mm
- Malign nodes: Short axis diameter ≥5 mm
Extramural vascular invasion
Downloads
- [1] Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 1.45 1.46 Beets-Tan, Regina G. H.; Lambregts, Doenja M. J.; Maas, Monique; Bipat, Shandra; Barbaro, Brunella; Curvo-Semedo, Luís; Fenlon, Helen M.; Gollub, Marc J.; et al. (2017). "Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting ". European Radiology 28 (4): 1465–1475. doi:. ISSN 0938-7994.
