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Comparison of Magnetic Resonance Imaging and Histopathological Response to Chemoradiotherapy in Locally Advanced Rectal Cancer

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Magnetic resonance imaging (MRI) methods for chemoradiotherapy (CRT) response assessment of rectal cancer include posttreatment T staging (ymrT), tumor regression grading (mrTRG), volume reduction posttreatment, and modified RECIST measurement. We compared these methods in identifying good versus poor responders with the histopathological standards of T stage (ypT) and tumor regression grading (TRG).

Methods

A total of 86 patients underwent CRT in a prospective phase II trial for MRI-defined locally advanced rectal cancer. Two readers independently assessed MRIs for ymrT, mrTRG, volume change, and RECIST. Parameters for each case were categorized as good or poor response and analyzed against ypT and TRG by univariate logistic regression.

Results

A total of 83 patients had evaluable imaging, and 78 had final pathology (five did not undergo surgery). Of these, 34 patients had good response (ypT0-3a) and 44 had poor response (>ypT3a). Also, 27 patients had favorable pathologic TRG (predominant fibrosis) and 51 had unfavorable TRG (predominant tumor). Good mrTRG and ymr <T3b stage were both significantly (P = 0.001) associated with favorable pathology odds ratio [OR] = 16.11 (95 % confidence interval [95 % CI]: 3.36–77.29) and 17.50 (95 % CI: 5.38–56.89), respectively. RECIST measurements and volume reduction of >80 % showed an OR of 3.23 (95 % CI: 1.14–9.17), 4.25 (95 % CI: 0.92–15.45), respectively, for a good ypT score (P = 0.028), but there was no association for histopathological TRG.

Conclusion

Favorable and unfavorable histopathology are predicted by both ymrT and mrTRG, and we recommend these parameters for post-treatment assessment of rectal cancers treated with CRT.

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Acknowledgement

GB., H. R., D. S. M., R. G. J., E. R., M. P., S. R., C. V. V., and P. Q. were paid honoraria by Sanofi-Aventis for the design of study protocol. E.V.C. received research funding at the University Hospital Leuven paid by Sanofi-Aventis.

Author information

Authors and Affiliations

  1. Department of Radiology, The Royal Marsden Hospital, Sutton, UK

    Uday Bharat Patel MBBS, Gina Brown FRCR, MD & Pennert Kjell

  2. Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands

    Harm Rutten MD, PhD

  3. Section of Pathology and Tumor Biology, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK

    Nicholas West MBChB & Philip Quirke FRCPath, PhD

  4. St James’s Institute of Oncology, Leeds, UK

    David Sebag-Montefiore FRCR,FRCP

  5. Department of Clinical Oncology, Mount Vernon Cancer Center, Northwood, UK

    Robert Glynne-Jones FRCR, FRCP

  6. Department of Surgery, Saint-Andre Hospital, Bordeaux, France

    Eric Rullier MD

  7. Digestive Oncology Unit, University Hospital Ghent, Ghent, Belgium

    Marc Peeters MD, PhD

  8. Digestive Oncology, University Hospital Gasthuisberg/Leuven, Leuven, Belgium

    Eric Van Cutsem MD, PhD

  9. Department of Medical Oncology, Santa Chiara Hospital, Pisa, Italy

    Sergio Ricci MD, PhD

  10. Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands

    Cornelius Van de Velde MD, PhD

Authors
  1. Uday Bharat Patel MBBS
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  2. Gina Brown FRCR, MD
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Corresponding author

Correspondence to Gina Brown FRCR, MD.

Appendices

APPENDIX 1. MRI TECHNIQUE

Hardware

Magnet

A 1.5T system should be used.

Coil

Surface coils are not recommended in the routine staging of rectal cancer.

Phased array coils gain the advantages of the surface coil by obtaining higher signal but with greater coverage than a single surface coil and improved homogeneity.

Coil positioning. It is important in rectal cancers that the coil is correctly centered to the whole rectum. Thus, the lower edge of the coil needs to be placed 5 cm below the symphysis pubis to ensure adequate signal is obtained from the lower rectum and anorectal junction

Suggested Sequences

The initial sequences performed are the localization images, coronal and sagittal to image the tumor and plan the high-resolution images that are performed axial to the rectum (Tables 5 and 6).

Table 5 Image acquisition parameters for the first 2 planned series for different machines
Full size table
Table 6 High-resolution oblique axial scan parameters
Full size table

The first series is the sagittal T2W-FSE.

The second series is a large field-of-view axial section of the whole pelvis from the iliac crest to the symphasis pubis.

Sequence 3: While the second series is being acquired, the high-resolution images can be planned. The sagittal T2 weighted images obtained are used to planT2-weighted thin-section axial images through the rectal cancer and adjacent perirectal tissues. It is critical that these images are performed perpendicular to the long axis of the rectum. The images are obtained by using a 16-cm field of view, a 3-mm section thickness, and no intersection gap.

APPENDIX 2. EXAMPLES OF ymrT3a-T3d

Figs. 3,4,5, and 6.

Fig. 3
figure 3

Stage T3a rectal cancer. a Thin-section T2 weighted axial MR images shows a T3a rectal cancer (curved arrow), with extension of less than 1 mm beyond the muscularis propria. The invasive margin is at the 11 o’clock position. b Section of the explanted rectum shows tumor invasion at the 11 o’clock position (curved arrow)

Full size image
Fig. 4
figure 4

Stage T3b rectal cancer. a and b Thin-section T2 weighted axial MR images show baseline a and post-CRT b images of a T3b rectal cancer, with extension of 3 mm beyond the muscularis propria on both images. The invasive margin is at the 4 o’clock position (curved arrow). c Micrograph (original magnification ×0.4, hematoxylin–eosin [H–E] stain) shows neoplastic glands (curved arrow) extending beyond the muscularis propria (arrowheads)

Full size image
Fig. 5
figure 5

Stage T3c rectal cancer. a Thin-section T2 weighted axial MR images show baseline a images of a T3c rectal cancer with tumor invasion at the 6 o’clock and 10 o’clock positions (curved arrows). There is 10-mm and of 8-mm invasion from the muscularis propria, respectively. b and c Post-CRT thin-section T2 weighted axial MR images b, with corresponding micrograph c (original magnification ×0.1, hematoxylin–eosin [H–E] stain) shows tumor (curved arrow) with extension of 8 mm beyond the muscularis propria (arrowheads) on both images

Full size image
Fig. 6
figure 6

Stage T3d rectal cancer. a A T2 weighted sagittal MR shows a baseline T3d rectal cancer, with extension (curved arrow) of greater than 15 mm beyond the muscularis propria. b Post-CRT thin-section T2 weighted axial images show the invasive margin (curved arrow) at the 7 o’clock position. The arrowhead indicates the muscularis propria. c Micrograph (original magnification ×0.4, hematoxylin–eosin (H–E) stain) shows neoplastic glands (arrow) extending beyond the muscularis propria (arrowheads)

Full size image

APPENDIX 3. RAW DATA FOR INTEROBSERVER AGREEMENT

Tables 7, 8, 9, and 10.

Table 7 Raw data for ymrTRG
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Table 8 Raw data for ymrT
Full size table
Table 9 Raw data for mrRECIST
Full size table
Table 10 Raw data for mrVolumetric analysis
Full size table

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Patel, U.B., Brown, G., Rutten, H. et al. Comparison of Magnetic Resonance Imaging and Histopathological Response to Chemoradiotherapy in Locally Advanced Rectal Cancer. Ann Surg Oncol 19, 2842–2852 (2012). https://doi.org/10.1245/s10434-012-2309-3

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