Abstract
Objectives
To determine the appearance of rectal cancer on MRI after oxaliplatin-based chemotherapy (ICT) and make a preliminary assessment of MRI’s value in predicting response to total neoadjuvant treatment (TNT).
Methods
In this IRB-approved, HIPAA-compliant, retrospective study between 1 January 2010–20 October 2014, pre- and post-ICT tumour T2 volume, relative T2 signal intensity (rT2SI), node size, signal intensity and border characteristics were assessed in 63 patients (65 tumours) by three readers. The strength of association between the reference standard of histopathological percent tumour response and tumour volume change, rT2SI and lymph node characteristics was assessed with Spearman’s correlation coefficient and Wilcoxon’s rank sum test. Cox regression was used to assess association between DFS and radiological measures.
Results
Change in T2 volume was not associated with TNT response. Change in rT2SI showed correlation with TNT response for one reader only using selective regions of interest (ROIs) and borderline correlation with response using total volume ROI. There was a significant negative correlation between baseline and post-ICT node size and TNT response (r = -0.25, p = 0.05; r = -0.35, p = 0.005, readers 1 and 2, respectively). Both baseline and post-induction median node sizes were significantly smaller in complete responders (p = 0.03, 0.001; readers 1 and 2, respectively). Change in largest baseline node size and decrease in post-ICT node signal heterogeneity were associated with 100% tumour response (p = 0.04). Nodal sizes at baseline and post-ICT MRI correlated with DFS.
Conclusion
In patients undergoing post-ICT MRI, tumour volume did not correlate with TNT response, but decreased lymph node sizes were significantly associated with complete response to TNT as well as DFS. Relative T2SI showed borderline correlation with TNT response.
Key Points
• MRI-based tumour volume after induction chemotherapy and before chemoradiotherapy did not correlate with overall tumour response at the end of all treatment.
• Lymph node size after induction chemotherapy and before chemoradiotherapy was strongly associated with complete pathological response after all treatment.
• Lymph node sizes at baseline and post-induction chemotherapy MRI correlated with disease-free survival.
Similar content being viewed by others
Abbreviations
- CapeOX:
-
Capecitabine-oxaliplatin
- CRT:
-
Chemoradiotherapy
- DCE-MRI:
-
Dynamic contrast-enhanced sequences
- DFS:
-
Disease-free survival
- DWI:
-
Diffusion-weighted imaging
- FOLFIRINOX:
-
5-Fluorouracil-irinotecan-oxaliplatin
- FOLFOX 5:
-
5-Fluorouracil-leucovorin-oxaliplatin
- ICT:
-
Upfront chemotherapy (‘induction’)
- IQR:
-
Interquartile range
- mrTRG:
-
Magnetic resonance tumour regression grade
- pCR:
-
Pathological complete response
- rT2SI:
-
Relative T2 signal intensity
- TME:
-
Total mesorectal excision
- TNT:
-
Total neoadjuvant treatment
- XELOX:
-
Xeloda-oxaliplatin
References
Barbaro B, Fiorucci C, Tebala C et al (2009) Locally Advanced Rectal Cancer: MR Imaging in Prediction of Response after Preoperative Chemotherapy and Radiation Therapy. Radiology 250:730–739
Blazic IM, Campbell NM, Gollub MJ (2016) MRI for evaluation of treatment response in rectal cancer. Br J Radiol 89:20150964
Cercek A, Goodman KA, Hajj C et al (2014) Neoadjuvant Chemotherapy First, Followed by Chemoradiation and then Surgery, in the Management of Locally Advanced Rectal Cancer. J Natl Compr Canc Netw 12:513–519
NCCN 2017 guidelines, page 49: https://www.nccn.org/patients/guidelines/colon/files/assets/common/downloads/files/colon.pdf.
Glynne-Jones R, Wyrwicz L, Tiret E et al, on behalf of the ESMO Guidelines Committee (2017) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 28(suppl_4):iv22–iv40
Sclafani F, Brown G, Cunningham D et al (2016) PAN-EX: a pooled analysis of two trials of neoadjuvant chemotherapy followed by chemoradiotherapy in MRI-defined, locally advanced rectal cancer. Ann Oncol 27(8):1557–1565
Patel UB, Brown G, Machado I et al (2017) MRI assessment and outcomes in patients receiving neoadjuvant chemotherapy only for primary rectal cancer: long-term results from the GEMCAD 0801 trial. Ann Oncol 28:344–353
Sassen S, de Booij M, Sosef M et al (2013) Locally advanced rectal cancer: is diffusion weighted MRI helpful for the identification of complete responders (ypT0N0) after neoadjuvant chemoradiation therapy? Eur Radiol 23(12):3440–3449
Hötker AM, Tarlinton L, Mazaheri Y et al (2016) Multiparametric MRI in the assessment of response of rectal cancer to neoadjuvant chemoradiotherapy: A comparison of morphological, volumetric and functional MRI parameters. Eur Radiol 26:4303–4312
Kluza E, Rozeboom ED, Maas M et al (2013) T2 weighted signal intensity evolution may predict pathological complete response after treatment for rectal cancer. Eur Radiol 23(1):253–261
Brown G, Richards CJ, Bourne MW et al (2003) Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 227(2):371–377
Kim JH, Beets GL, Kim MJ, Kessels AG, Beets-Tan RG (2004) High-resolution MR imaging for nodal staging in rectal cancer: are there any criteria in addition to the size? Eur J Radiol 52(1):78–83
Shia J, Guillem JG, Moore HG et al (2004) Patterns of morphologic alteration in residual rectal carcinoma following preoperative chemoradiation and their association with long-term outcome. Am J Surg Pathol 28(2):215–223
Trakarnsanga A, Gönen M, Shia J et al (2014) Comparison of tumor regression grade systems for locally advanced rectal cancer after multimodality treatment. J Natl Cancer Inst 106(10):1–6
Nougaret S, Rouanet P, Molinari N et al (2012) MR volumetric measurement of low rectal cancer helps predict tumor response and outcome after combined chemotherapy and radiation therapy. Radiology 263(2):409–418
Lambregts DM, Rao SX, Sassen S et al (2015) MRI and Diffusion-weighted MRI Volumetry for Identification of Complete Tumor Responders after Preoperative Chemoradiotherapy in Patients with Rectal Cancer: A Bi-institutional Validation Study. Ann Surg 262(6):1034–1039
Chua YJ, Barbachano Y, Cunningham D et al (2010) Neoadjuvant Capecitabine before chemoradiotherapy and total mesorectal excision in MRI-defined poor-risk rectal cancer: a phase 2 trial. Lancet Oncol 11(3):241–248
Nougaret S, Fujii S, Addley HC et al (2013) Neoadjuvant chemotherapy evaluation by MRI volumetry in rectal cancer followed by chemoradiation and total mesorectal excision: Initial experience. J Magn Reson Imaging 38(3):726–732
Aiba T, Uehara K, Nihashi T et al (2014) MRI and FDG-PET for assessment of response to neoadjuvant chemotherapy in locally advanced rectal cancer. Ann Surg Oncol 21(6):1801–1808
Seierstad T, Hole KH, Grøholt KK et al (2015) MRI volumetry for prediction of tumor response to neoadjuvant chemotherapy followed by chemoradiotherapy in locally advanced rectal cancer. Br J Radiol 88(1051):20150097
Lahaye MJ, Beets GL, Engelen SM et al (2009) Locally advanced rectal cancer: MR imaging for restaging after neoadjuvant radiation therapy with concomitant chemotherapy. Part II. What are the criteria to predict involved lymph nodes? Radiology 252(1):81–91
Weiser MR, Fichera A, Schrag D, Boughey JC, You YN (2015) Progress in the PROSPECT trial: precision treatment for rectal cancer? Bull Am Coll Surg 100(4):51–52
Lambregts DM, Beets GL, Maas M et al (2011) Tumour ADC measurements in rectal cancer: effect of ROI methods on ADC values and interobserver variability. Eur Radiol 21(12):2567–2574. https://doi.org/10.1007/s00330-011-2220-5
Blazic IM, Lilic GB, Gajic MM (2017) Quantitative Assessment of Rectal Cancer Response to Neoadjuvant Combined Chemotherapy and Radiation Therapy: Comparison of Three Methods of Positioning Region of Interest for ADC Measurements at Diffusion-weighted MR Imaging. Radiology 282(2):418–428. https://doi.org/10.1148/radiol.2016151908
Funding
This study has received funding by the National Cancer Institute of the National Institutes of Health under Award Number R25CA020449. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Guarantor
The scientific guarantor of this publication is Marc J. Gollub
Conflict of Interest
The authors of this article declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Statistics and Biometry
Andrea Knezevic and Mithat Gonen kindly provided statistical advice for this article.
No complex statistical methods were necessary for this paper.
Informed Consent
Written informed consent was waived by the Institutional Review Board.
Ethical Approval
Institutional Review Board approval was obtained.
Methodology
• Retrospective
• Cross-sectional study/observational
• Performed at one institution
Rights and permissions
About this article
Cite this article
Gollub, M.J., Blazic, I., Bates, D.D.B. et al. Pelvic MRI after induction chemotherapy and before long-course chemoradiation therapy for rectal cancer: What are the imaging findings?. Eur Radiol 29, 1733–1742 (2019). https://doi.org/10.1007/s00330-018-5726-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-018-5726-2