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Pelvic MRI after induction chemotherapy and before long-course chemoradiation therapy for rectal cancer: What are the imaging findings?

  • Gastrointestinal
  • Published:
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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.

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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

  1. 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

    Article  PubMed  Google Scholar 

  2. Blazic IM, Campbell NM, Gollub MJ (2016) MRI for evaluation of treatment response in rectal cancer. Br J Radiol 89:20150964

    Article  PubMed  PubMed Central  Google Scholar 

  3. 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

    Article  PubMed  PubMed Central  Google Scholar 

  4. NCCN 2017 guidelines, page 49: https://www.nccn.org/patients/guidelines/colon/files/assets/common/downloads/files/colon.pdf.

  5. 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

  6. 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

    Article  CAS  PubMed  Google Scholar 

  7. 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

    Article  CAS  PubMed  Google Scholar 

  8. 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

    Article  CAS  PubMed  Google Scholar 

  9. 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

    Article  PubMed  PubMed Central  Google Scholar 

  10. 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

    Article  PubMed  Google Scholar 

  11. 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

    Article  PubMed  Google Scholar 

  12. 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

  13. 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

  14. 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

    Article  CAS  Google Scholar 

  15. 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

    Article  PubMed  Google Scholar 

  16. 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

    Article  PubMed  Google Scholar 

  17. 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

    Article  CAS  PubMed  Google Scholar 

  18. 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

    Article  PubMed  Google Scholar 

  19. 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

    Article  PubMed  Google Scholar 

  20. 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

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. 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

    Article  PubMed  Google Scholar 

  22. 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

    PubMed  Google Scholar 

  23. 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

    Article  PubMed  PubMed Central  Google Scholar 

  24. 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

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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

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Correspondence to Marc J. Gollub.

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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

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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

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  • DOI: https://doi.org/10.1007/s00330-018-5726-2

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