European Radiology

, Volume 21, Issue 5, pp 987–995 | Cite as

Apparent diffusion coefficient for evaluating tumour response to neoadjuvant chemoradiation therapy for locally advanced rectal cancer

  • Seung Ho Kim
  • Jae Young Lee
  • Jeong Min Lee
  • Joon Koo Han
  • Byung Ihn Choi



To determine whether change in the apparent diffusion coefficient (ADC) before and after neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer (LARC) would more accurately predict pathological complete response (pCR) than analysing the pre- or post-CRT ADC individually.


76 patients with LARC (≥T3 or lymph node-positive) underwent pre- and post-CRT, 1.5-T diffusion-weighted imaging. A blinded radiologist measured the tumour ADCs. The three measures were compared with regard to CR and non-CR. To calculate accuracy for determining pCR, receiver-operating characteristic curve (ROC) analysis was applied to the three measures.


The post-CRT ADC (1.43 ± 0.10) (×10−3 mm2/s) and the percentage change (70.0 ± 23.5%) in the CR (n = 11) were significantly higher than those in the non-CR (n = 65) (1.14 ± 0.18, 30.2 ± 21.7%, respectively)(both, P < 0.0001). The pre-CRT ADC (0.85 ± 0.10) of the pCR did not differ significantly from that of the non-pCR (0.88 ± 0.14)(P = 0.4094). The post-CRT ADC showed comparable relative accuracy for determining pCR to that of the percentage change (P = 0.788). However, overall accuracy of the former (87%) was higher than that of the latter (75%) (P = 0.049).


Analyzing post-CRT ADC alone can reliably differentiate pCR from non-pCR in LARC


Rectum Neoplasms Chemoradiation Apparent diffusion coefficient Diffusion-weighted magnetic resonance imaging 



We thank In Chan Song, PhD, for technical assistance with the data acquisition. This study was supported by a grant of the Korea Healthcare technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea. (A070001)


  1. 1.
    Janjan NA, Crane C, Feig BW et al (2001) Improved overall survival among responders to preoperative chemoradiation for locally advanced rectal cancer. Am J Clin Oncol 24:107–112PubMedCrossRefGoogle Scholar
  2. 2.
    Valentini V, Coco C, Picciocchi A et al (2002) Does downstaging predict improved outcome after preoperative chemoradiation for extraperitoneal locally advanced rectal cancer? A long term analysis of 165 patients. Int J Radiat Oncol Biol Phys 53:664–674PubMedCrossRefGoogle Scholar
  3. 3.
    Theodoropoulos G, Wise WE, Padmanabhan A et al (2002) T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival. Dis Colon Rectum 45:895–903PubMedCrossRefGoogle Scholar
  4. 4.
    Garcia-Aguilar J, Hernandez de Anda E, Sirivongs P, Lee SH, Madoff RD, Rothenberger DA (2003) A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 46:298–304PubMedCrossRefGoogle Scholar
  5. 5.
    Chan AK, Wong A, Jenken D, Heine J, Buie D, Johnson D (2005) Posttreatment TNM staging is a prognostic indicator of survival and recurrence in tethered or fixed rectal carcinoma after preoperative chemotherapy and radiotherapy. Int J Radiat Oncol Biol Phys 61:665–677PubMedCrossRefGoogle Scholar
  6. 6.
    Hartley A, Ho K, McConkey C et al (2005) Pathological complete response following pre-operative chemoradiotherapy in rectal cancer: analysis of phase II/III trials. Br J Radiol 78:934–938PubMedCrossRefGoogle Scholar
  7. 7.
    Stipa F, Chessin DB, Shia J et al (2006) A pathologic complete response of rectal cancer to preoperative combined-modality therapy results in improved oncological outcome compared with those who achieved no downstaging on the basis of preoperative endorectal ultrasonography. Ann Surg Oncol 13:1047–1053PubMedCrossRefGoogle Scholar
  8. 8.
    Hughes R, Glynne-Jones R, Grainger J et al (2006) Can pathological complete response in the primary tumour following pre-operative pelvic chemoradiotherapy for T3–T4 rectal cancer predict for sterilisation of pelvic lymph nodes, a low risk of local recurrence and the appropriateness of local excision? Int J Colorectal Dis 21:11–17PubMedCrossRefGoogle Scholar
  9. 9.
    Byrd DR, Compton CC, Fritz AG, Trotti A III (2009) Colon and rectum. In: Edge SB (ed) AJCC Cancer Staging Manual, 7th edn. Springer, New York, pp 143–159Google Scholar
  10. 10.
    Maas M, Lambregts DMJ, Nelemans PJ, Beets GL, Beets-Tan RG (2010) Response after chemoradiation in rectal cancer is associated with improved long-term outcome: a pooled analysis (abstr). In: European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Annual Meeting Program. Dresden, GermanyGoogle Scholar
  11. 11.
    Brown CL, Ternent CA, Thorson AG et al (2003) Response to preoperative chemoradiation in stage II and III rectal cancer. Dis Colon Rectum 46:1189–1193PubMedCrossRefGoogle Scholar
  12. 12.
    Bonnen M, Crane C, Vauthey J et al (2004) Long-term results using local excision after preoperative chemoradiation among selected T3 cancer patients. Int J Radiat Oncol Biol Phys 60:1098–1105PubMedCrossRefGoogle Scholar
  13. 13.
    Habr-Gama A, Perez R, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240:711–717PubMedGoogle Scholar
  14. 14.
    O'Neill BD, Brown G, Heald RJ, Cunningham D, Tait DM (2007) Non-operative treatment after neoadjuvant chemoradiotherapy for rectal cancer. Lancet Oncol 8:625–633PubMedCrossRefGoogle Scholar
  15. 15.
    Bujko K, Kepka L, Nowacki MP (2007) Chemoradiotherapy alone for rectal cancer: a word of caution. Lancet Oncol 8:860–862PubMedCrossRefGoogle Scholar
  16. 16.
    Den Dulk M, Van de Velde CJ (2007) Considerations and restrictions for non-operative treatment of rectal cancer in selected patients. Lancet Oncol 8:570–571CrossRefGoogle Scholar
  17. 17.
    Borschitz T, Wachtlin D, Mohler M, Schmidberger H, Junginger T (2008) Neoadjuvant chemoradiation and local excision for T2-3 rectal cancer. Ann Surg Oncol 15:712–720PubMedCrossRefGoogle Scholar
  18. 18.
    Koh DM, Padhani AR (2006) Diffusion-weighted MRI: a new functional clinical technique for tumor imaging. Br J Radiol 79:633–635PubMedCrossRefGoogle Scholar
  19. 19.
    Koh DM, Collins DJ (2007) Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 188:1622–1635PubMedCrossRefGoogle Scholar
  20. 20.
    Patterson DM, Padhani AR, Collins DJ (2008) Technology insight: water diffusion MRI—a potential new biomarker of response to cancer therapy. Nat Clin Pract Oncol 5:220–233PubMedCrossRefGoogle Scholar
  21. 21.
    Padhani AR, Liu G, Koh DM et al (2009) Diffusion-weighted magnetic resonance imaging as a cancer biomarker: consensus and recommendations. Neoplasia 11:102–125PubMedGoogle Scholar
  22. 22.
    Abdel Razek AA, Kandeel AY, Soliman N et al (2007) Role of diffusion-weighted echo-planar MR imaging in differentiation of residual or recurrent head and neck tumors and posttreatment changes. AJNR Am J Neuroradiol 28:1146–1152PubMedCrossRefGoogle Scholar
  23. 23.
    Abdel Razek AA, Megahed AS, Denewer A, Motamed A, Tawfik A, Nada N (2008) Role of diffusion-weighted magnetic resonance imaging in differentiation between the viable and necrotic parts of head and neck tumors. Acta Radiol 49:364–370CrossRefGoogle Scholar
  24. 24.
    Dzik-Jurasz A, Domenig C, George M et al (2002) Diffusion MRI for prediction of response of rectal cancer to chemoradiation. Lancet 360:307–308PubMedCrossRefGoogle Scholar
  25. 25.
    Kremser C, Judmaier W, Hein P, Griebel J, Lukas P, de Vries A (2003) Preliminary results on the influence of chemoradiation on apparent diffusion coefficients of primary rectal carcinoma measured by magnetic resonance imaging. Strahlenther Onkol 179:641–649PubMedCrossRefGoogle Scholar
  26. 26.
    DeVries AF, Kremser C, Hein PA et al (2003) Tumor microcirculation and diffusion predict therapy outcome for primary rectal carcinoma. Int J Radiat Oncol Biol Phys 56:958–965PubMedCrossRefGoogle Scholar
  27. 27.
    Kim SH, Lee JM, Hong SH, Kim KH, Han JK, Choi BI (2009) Locally advanced rectal cancer: added value of diffusion-weighted MR imaging in the evaluation of tumor response to neoadjuvant chemo-and radiation therapy. Radiology 253:116–125PubMedCrossRefGoogle Scholar
  28. 28.
    Hein PA, Kremser C, Judmaier W et al (2003) Diffusion-weighted magnetic resonance imaging for monitoring diffusion changes in rectal carcinoma during combined, preoperative chemoradiation: preliminary results of a prospective study. Eur J Radiol 45:214–222PubMedCrossRefGoogle Scholar
  29. 29.
    Sun YS, Zhang XP, Tang L et al (2010) Locally advanced rectal carcinoma treated with preoperative chemotherapy and radiation therapy: preliminary analysis of diffusion-weighted MR imaging for early detection of tumor histopathologic downstaging. Radiology 254:170–178PubMedCrossRefGoogle Scholar
  30. 30.
    Greene FL, Page DL, Fleming ID et al (2002) Colon and rectum. In: Fritz AG (ed) AJCC Cancer Staging Manual, 6th edn. Springer, New York, pp 113–124CrossRefGoogle Scholar
  31. 31.
    Dworak O, Keilholz L, Hoffmann A (1997) Pathological features of rectal cancer after preoperative of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis 12:19–23PubMedCrossRefGoogle Scholar
  32. 32.
    Kim YH, Kim DY, Kim TH et al (2005) Usefulness of magnetic resonance volumetric evaluation in predicting response to preoperative concurrent chemoradiotherapy in patients with resectable rectal cancer. Int J Radiat Oncol Biol Phys 62:761–768PubMedCrossRefGoogle Scholar
  33. 33.
    Kim SH, Lee JM, Park HS, Eun HW, Han JK, Choi BI (2009) Accuracy of MRI for predicting the circumferential resection margin, mesorectal fascia invasion and tumor response to neoadjuvant chemoradiotherapy for locally advanced rectal cancer. J Magn Reson Imaging 29:1093–1101PubMedCrossRefGoogle Scholar
  34. 34.
    Kim SH, Lee JM, Lee MW, Kim GH, Han JK, Choi BI (2008) Ultrasound transmission gel as an endorectal contrast agent for tumor visualization of rectal cancer. Am J Roentgenol 191:186–189CrossRefGoogle Scholar
  35. 35.
    Kim SH, Lee JM, Lee MW, Kim GH, Han JK, Choi BI (2008) Diagnostic accuracy of 3.0-Tesla rectal magnetic resonance imaging in preoperative local staging of primary rectal cancer. Invest Radiol 43:587–593PubMedCrossRefGoogle Scholar
  36. 36.
    Shihab OC, Moran BJ, Heald RJ, Quirke P, Brown G (2009) MRI staging of low rectal cancer. Eur Radiol 19:643–650PubMedCrossRefGoogle Scholar
  37. 37.
    Norman GR, Streiner DL et al (2003) PDQ Statistics, 3rd edn. Decker Inc, Hamilton, pp 91–92Google Scholar
  38. 38.
    Heo S, Jeong S, Young J et al (2010) A comparative study of histopathologic parameters and apparent diffusion coefficient values on 3T rectal MRI in locally advanced rectal cancer following neoadjuvant chemoradiation therapy (abstr). In: European Congress of Radiology (ECR) Annual Meeting Program. Vienna, AustriaGoogle Scholar
  39. 39.
    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 250:730–739PubMedCrossRefGoogle Scholar
  40. 40.
    Dresen RC, Beets GL, Rutten HJT et al (2009) Locally advanced rectal cancer: MR imaging for restaging after neoadjuvant radiation therapy with concomitant chemotherapy part I. are we able to predict tumor confined to the rectal wall? Radiology 252:71–80PubMedCrossRefGoogle Scholar
  41. 41.
    Denecke T, Rau B, Hoffmann KT et al (2005) Comparison of CT, MRI and FDG-PET in response prediction of patients with locally advanced rectal cancer after multimodal preoperative therapy: is there a benefit in using functional imaging? Eur Radiol 15:1658–1666PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2010

Authors and Affiliations

  • Seung Ho Kim
    • 1
  • Jae Young Lee
    • 1
  • Jeong Min Lee
    • 1
  • Joon Koo Han
    • 1
  • Byung Ihn Choi
    • 1
  1. 1.Department of RadiologySeoul National University College of MedicineSeoulSouth Korea

Personalised recommendations