Abdominal Radiology

, Volume 44, Issue 11, pp 3536–3548 | Cite as

Rectal cancer MR staging: pearls and pitfalls at baseline examination

  • Stephanie NougaretEmail author
  • Kartik Jhaveri
  • Zahra Kassam
  • Chandana Lall
  • David H. Kim
Special Section: Rectal Cancer


In recent years, rectal MRI has become a central diagnostic tool in rectal cancer staging. Indeed, rectal MR has the ability to accurately evaluate a number of important findings that may impact patient management, including distance of the tumor to the mesorectal fascia, presence of extramural vascular invasion (EMVI), presence of lymph nodes, and involvement of the peritoneum/anterior peritoneal reflection. Many of these findings are difficult to assess in nonexpert hands. In this review, we present a practical approach for radiologists to provide high-quality interpretations at initial baseline exams, based on recent guidelines from the Society of Abdominal Radiology, Rectal and Anal Cancer Disease Focused Panel. Practical pearls and pitfalls are discussed, focusing on optimization of technique including, patient preparation and protocol recommendations, interpretation, and essentials of reporting.


Rectal cancer Staging MRI Protocol Reporting 


Compliance with ethical standards

Conflict of interest

Disclosures for David H Kim: Shareholder for Elucent and Cellectar. The authors Stephanie Nougaret, Kartik Jhaveri, Zahra Kassam, Chandana Lall have declare that they have no conflict of interest.


  1. 1.
    Sauer R, Becker H, Hohenberger W et al (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Eng J JMed 351:1731-1740CrossRefGoogle Scholar
  2. 2.
    Horvat N, Petkovska I, Gollub MJ (2018) MR Imaging of Rectal Cancer. Radiol Clin N Am 56:75CrossRefGoogle Scholar
  3. 3.
    Gollub MJ, Arya S, Beets-Tan RGH et al (2018) Use of magnetic resonance imaging in rectal cancer patients: Society of Abdominal Radiology (SAR) rectal cancer disease-focused panel (DFP) recommendations 2017. Abdom Radiol 43:2893-2902CrossRefGoogle Scholar
  4. 4.
    (2017) Commision on Cancer. National Accreditation Program for Rectal Cancer Standards Manual. Am Coll Surg,, pp 1-61
  5. 5.
    Ioannidis A, Konstantinidis M, Apostolakis S, Koutserimpas C, Machairas N, Konstantinidis KM (2018) Impact of multidisciplinary tumor boards on patients with rectal cancer. Mol Clin Oncol 9:135-137PubMedPubMedCentralGoogle Scholar
  6. 6.
    Beets-Tan RG, Lambregts DM, Maas M et al (2013) 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 23:2522-2531CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Gollub MJ, Arya S, Beets-Tan RG et al (2018) Use of magnetic resonance imaging in rectal cancer patients: Society of Abdominal Radiology (SAR) rectal cancer disease-focused panel (DFP) recommendations 2017. Abdom Radiol (NY) 43:2893-2902CrossRefGoogle Scholar
  8. 8.
    Slater A, Halligan S, Taylor SA, Marshall M (2006) Distance between the rectal wall and mesorectal fascia measured by MRI: Effect of rectal distension and implications for preoperative prediction of a tumour-free circumferential resection margin. Clin Radiol 61:65-70CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Ye F, Zhang H, Liang X, Ouyang H, Zhao X, Zhou C (2016) JOURNAL CLUB: Preoperative MRI Evaluation of Primary Rectal Cancer: Intrasubject Comparison With and Without Rectal Distention. AJR Am J Roentgenol 207:32-39CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    van Griethuysen JJM, Bus EM, Hauptmann M et al (2018) Gas-induced susceptibility artefacts on diffusion-weighted MRI of the rectum at 1.5T - Effect of applying a micro-enema to improve image quality. Eur J Radiol 99:131-137CrossRefPubMedGoogle Scholar
  11. 11.
    Beets-Tan RGH, Lambregts DMJ, Maas M et al (2018) Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 28:1465-1475CrossRefGoogle Scholar
  12. 12.
    Okizuka H, Sugimura K, Yoshizako T, Kaji Y, Wada A (1996) Rectal carcinoma: prospective comparison of conventional and gadopentetate dimeglumine enhanced fat-suppressed MR imaging. J Magn Reson Imaging 6:465-471CrossRefPubMedGoogle Scholar
  13. 13.
    Vliegen RF, Beets GL, von Meyenfeldt MF et al (2005) Rectal cancer: MR imaging in local staging–is gadolinium-based contrast material helpful? Radiology 234:179-188CrossRefGoogle Scholar
  14. 14.
    Alberda WJ, Dassen HP, Dwarkasing RS et al (2013) Prediction of tumor stage and lymph node involvement with dynamic contrast-enhanced MRI after chemoradiotherapy for locally advanced rectal cancer. Int J Colorectal Dis 28:573-580CrossRefPubMedGoogle Scholar
  15. 15.
    Rudisch A, Kremser C, Judmaier W, Zunterer H, DeVries AF (2005) Dynamic contrast-enhanced magnetic resonance imaging: a non-invasive method to evaluate significant differences between malignant and normal tissue. Eur J Radiol 53:514-519CrossRefPubMedGoogle Scholar
  16. 16.
    Greene FL, Stewart AK, Norton HJ (2004) New tumor-node-metastasis staging strategy for node-positive (stage III) rectal cancer: an analysis. J Clin Oncol 22:1778-1784CrossRefPubMedGoogle Scholar
  17. 17.
    Taylor F, Mangat N, Swift IR, Brown G (2010) Proforma-based reporting in rectal cancer. Cancer Imaging 10 Spec no A:S142-150Google Scholar
  18. 18.
    Al-Sukhni E, Messenger DE, Charles Victor J, McLeod RS, Kennedy ED (2013) Do MRI reports contain adequate preoperative staging information for end users to make appropriate treatment decisions for rectal cancer? Ann Surg Oncol 20:1148-1155CrossRefPubMedGoogle Scholar
  19. 19.
    Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G (2013) The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the "DISTANCE"? Radiology 268:330-344CrossRefGoogle Scholar
  20. 20.
    Akasu T, Iinuma G, Fujita T et al (2005) Thin-section MRI with a phased-array coil for preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer. AJR Am J Roentgenol 184:531-538CrossRefPubMedGoogle Scholar
  21. 21.
    Stelzner S, Holm T, Moran BJ et al (2011) Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 54:947-957CrossRefPubMedGoogle Scholar
  22. 22.
    Tsukada Y, Ito M, Watanabe K et al (2016) Topographic Anatomy of the Anal Sphincter Complex and Levator Ani Muscle as It Relates to Intersphincteric Resection for Very Low Rectal Disease. Dis Colon Rectum 59:426-433CrossRefPubMedGoogle Scholar
  23. 23.
    Gollub MJ, Maas M, Weiser M et al (2013) Recognition of the anterior peritoneal reflection at rectal MRI. AJR Am J Roentgenol 200:97-101CrossRefPubMedGoogle Scholar
  24. 24.
    McCawley N, Clancy C, O'Neill BD, Deasy J, McNamara DA, Burke JP (2016) Mucinous Rectal Adenocarcinoma Is Associated with a Poor Response to Neoadjuvant Chemoradiotherapy: A Systematic Review and Meta-analysis. Dis Colon Rectum 59:1200-1208CrossRefGoogle Scholar
  25. 25.
    Oberholzer K, Menig M, Kreft A et al (2012) Rectal cancer: mucinous carcinoma on magnetic resonance imaging indicates poor response to neoadjuvant chemoradiation. Int J Radiat Oncol Biol Phys 82:842-848CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Moran B, Brown G, Cunningham D et al (2008) Clarifying the TNM staging of rectal cancer in the context of modern imaging and neo-adjuvant treatment: 'y''u' and 'p' need 'mr' and 'ct'. Colorectal Dis 10:242-243CrossRefPubMedGoogle Scholar
  27. 27.
    Rao SX, Zeng MS, Xu JM et al (2007) Assessment of T staging and mesorectal fascia status using high-resolution MRI in rectal cancer with rectal distention. World J Gastroenterol 13:4141-4146CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Low RN, McCue M, Barone R, Saleh F, Song T (2003) MR staging of primary colorectal carcinoma: comparison with surgical and histopathologic findings. Abdom Imaging 28:784-793CrossRefPubMedGoogle Scholar
  29. 29.
    Maas M, Lambregts DM, Lahaye MJ et al (2012) T-staging of rectal cancer: accuracy of 3.0 Tesla MRI compared with 1.5 Tesla. Abdom Imaging 37:475-481CrossRefPubMedGoogle Scholar
  30. 30.
    Smith N, Brown G (2008) Preoperative staging of rectal cancer. Acta Oncol 47:20-31CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Taylor FG, Swift RI, Blomqvist L, Brown G (2008) A systematic approach to the interpretation of preoperative staging MRI for rectal cancer. AJR Am J Roentgenol 191:1827-1835CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Brown G (2004) Local radiological staging of rectal cancer. Clin Radiol 59:213-214CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Klessen C, Rogalla P, Taupitz M (2007) Local staging of rectal cancer: the current role of MRI. Eur Radiol 17:379-389CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Yeung JM, Ferris NJ, Lynch AC, Heriot AG (2009) Preoperative staging of rectal cancer. Future Oncol 5:1295-1306CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Beets-Tan RG, Beets GL, Vliegen RF et al (2001) Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet 357:497-504CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23:9257-9264CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Chamlou R, Parc Y, Simon T et al (2007) Long-term results of intersphincteric resection for low rectal cancer. Ann Surg 246:916-921; discussion 921-912Google Scholar
  38. 38.
    Anderin C, Martling A, Hellborg H, Holm T A population-based study on outcome in relation to the type of resection in low rectal cancer. Dis Colon Rectum 53:753-760Google Scholar
  39. 39.
    Habr-Gama A, de Souza PM, Ribeiro U, Jr. et al (1998) Low rectal cancer: impact of radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41:1087-1096CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ Patients with low rectal cancer treated by abdominoperineal excision have worse tumors and higher involved margin rates compared with patients treated by anterior resection. Dis Colon Rectum 53:53-56Google Scholar
  41. 41.
    Gerard JP, Chapet O, Nemoz C et al (2004) Improved sphincter preservation in low rectal cancer with high-dose preoperative radiotherapy: the lyon R96-02 randomized trial. J Clin Oncol 22:2404-2409CrossRefPubMedGoogle Scholar
  42. 42.
    Kao PS, Chang SC, Wang LW et al The impact of preoperative chemoradiotherapy on advanced low rectal cancer. J Surg Oncol 102:771-777Google Scholar
  43. 43.
    Weiser MR, Quah HM, Shia J et al (2009) Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg 249:236-242CrossRefPubMedGoogle Scholar
  44. 44.
    Rouanet P, Saint-Aubert B, Lemanski C et al (2002) Restorative and nonrestorative surgery for low rectal cancer after high-dose radiation: long-term oncologic and functional results. Dis Colon Rectum 45:305-313; discussion 313-305Google Scholar
  45. 45.
    Shihab OC, Moran BJ, Heald RJ, Quirke P, Brown G (2009) MRI staging of low rectal cancer. Eur Radiol 19:643-650CrossRefPubMedGoogle Scholar
  46. 46.
    Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT (2003) Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg 90:355-364CrossRefPubMedGoogle Scholar
  47. 47.
    Smith NJ, Shihab O, Arnaout A, Swift RI, Brown G (2008) MRI for detection of extramural vascular invasion in rectal cancer. AJR Am J Roentgenol 191:1517-1522CrossRefPubMedGoogle Scholar
  48. 48.
    Smith NJ, Barbachano Y, Norman AR, Swift RI, Abulafi AM, Brown G (2008) Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br J Surg 95:229-236CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Ale Ali H, Kirsch R, Razaz S et al (2018) Extramural venous invasion in rectal cancer: overview of imaging, histopathology, and clinical implications. Abdom Radiol (NY).
  50. 50.
    Jhaveri KS, Hosseini-Nik H, Thipphavong S et al (2016) MRI Detection of Extramural Venous Invasion in Rectal Cancer: Correlation With Histopathology Using Elastin Stain. AJR Am J Roentgenol 206:747-755CrossRefGoogle Scholar
  51. 51.
    Siddiqui MRS, Simillis C, Hunter C et al (2017) A meta-analysis comparing the risk of metastases in patients with rectal cancer and MRI-detected extramural vascular invasion (mrEMVI) vs mrEMVI-negative cases. Br J Cancer 116:1513-1519CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Group MS (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333:779CrossRefGoogle Scholar
  53. 53.
    Chand M, Palmer T, Blomqvist L, Nagtegaal I, West N, Brown G (2015) Evidence for radiological and histopathological prognostic importance of detecting extramural venous invasion in rectal cancer: recommendations for radiology and histopathology reporting. Colorectal Dis 17:468-473CrossRefPubMedGoogle Scholar
  54. 54.
    Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2:996-999CrossRefPubMedGoogle Scholar
  55. 55.
    Wibe A, Rendedal PR, Svensson E et al (2002) Prognostic significance of the circumferential resection margin following total mesorectal excision for rectal cancer. Br J Surg 89:327-334CrossRefPubMedGoogle Scholar
  56. 56.
    Adam IJ, Mohamdee MO, Martin IG et al (1994) Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 344:707-711CrossRefPubMedGoogle Scholar
  57. 57.
    Fritzmann J, Contin P, Reissfelder C et al (2018) Comparison of three classifications for lymph node evaluation in patients undergoing total mesorectal excision for rectal cancer. Langenbecks Arch Surg 403:451-462CrossRefPubMedGoogle Scholar
  58. 58.
    Grone J, Loch FN, Taupitz M, Schmidt C, Kreis ME (2018) Accuracy of Various Lymph Node Staging Criteria in Rectal Cancer with Magnetic Resonance Imaging. J Gastrointest Surg 22:146-153CrossRefPubMedGoogle Scholar
  59. 59.
    Schurink N, Lambregts D, Beets-Tan R (2018) Diffusion-weighted imaging in rectal cancer: current applications and future perspectives. Br J Radiol.
  60. 60.
    Mizukami Y, Ueda S, Mizumoto A et al (2011) Diffusion-weighted magnetic resonance imaging for detecting lymph node metastasis of rectal cancer. World J Surg 35:895-899CrossRefPubMedGoogle Scholar
  61. 61.
    Lahaye MJ, Engelen SM, Kessels AG et al (2008) USPIO-enhanced MR imaging for nodal staging in patients with primary rectal cancer: predictive criteria. Radiology 246:804-811CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Heijnen LA, Lambregts DM, Martens MH et al (2014) Performance of gadofosveset-enhanced MRI for staging rectal cancer nodes: can the initial promising results be reproduced? Eur Radiol 24:371-379CrossRefGoogle Scholar
  63. 63.
    Tse DM, Joshi N, Anderson EM, Brady M, Gleeson FV (2012) A computer-aided algorithm to quantitatively predict lymph node status on MRI in rectal cancer. Br J Radiol 85:1272-1278CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Chen Y, Yang X, Lu B, Xiao X, Zhuang X, Yu S (2018) [Diagnostic accuracy of 3.0T high-resolution MRI for assessment mesorectal lymph node metastases in patients with rectal cancer]. Zhonghua Wei Chang Wai Ke Za Zhi 21:786-792PubMedGoogle Scholar
  65. 65.
    Armbruster M, D'Anastasi M, Holzner V et al (2018) Improved detection of a tumorous involvement of the mesorectal fascia and locoregional lymph nodes in locally advanced rectal cancer using DCE-MRI. Int J Colorectal Dis 33:901-909CrossRefPubMedGoogle Scholar
  66. 66.
    Chen Y, Yang X, Wen Z et al (2018) Fat-suppressed gadolinium-enhanced isotropic high-resolution 3D-GRE-T1WI for predicting small node metastases in patients with rectal cancer. Cancer Imaging 18:21CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Yu J, Dai X, Zou HH et al (2018) Diffusion kurtosis imaging in identifying the malignancy of lymph nodes during the primary staging of rectal cancer. Colorectal Dis 20:116-125CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Stephanie Nougaret
    • 1
    • 2
    Email author
  • Kartik Jhaveri
    • 3
  • Zahra Kassam
    • 4
  • Chandana Lall
    • 5
  • David H. Kim
    • 6
  1. 1.Montpellier Cancer Research InstituteMontpellierFrance
  2. 2.Department of Radiology, Montpellier Cancer Institute, INSERM, U1194University of MontpellierMontpellierFrance
  3. 3.University of Toronto University Health NetworkTorontoCanada
  4. 4.Department of Medical Imaging, Schulich School of MedicineWestern UniversityLondonCanada
  5. 5.University of FloridaDepartment of Radiology, 655 W 8th StreetJacksonvilleUSA
  6. 6.School of Medicine and Public HealthUniversity of WisconsinMadisonUSA

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