European Radiology

, Volume 23, Issue 12, pp 3440–3449 | Cite as

Locally advanced rectal cancer: is diffusion weighted MRI helpful for the identification of complete responders (ypT0N0) after neoadjuvant chemoradiation therapy?

  • S. SassenEmail author
  • M. de Booij
  • M. Sosef
  • R. Berendsen
  • G. Lammering
  • R. Clarijs
  • M. Bakker
  • R. Beets-Tan
  • F. Warmerdam
  • R. Vliegen



To determine retrospectively the additional value of DWI-MRI toT2-MRI for predicting complete response (ypT0N0 = CR) after chemoradiation-therapy (CRT) in locally advanced rectal cancer.


Seventy locally advanced rectal cancer patients underwent CRT followed by restaging MRI and resection. Two readers with different experience levels independently scored T2 images for CR and, in a second reading, combined T2 and DWI. A 5-point confidence-level score was used to generate ROC curves. Areas under the ROC curves (AUC) and interobserver agreement were compared for both readings. Histology served as reference standard.


The interobserver agreement increased after addition of DWI from 0.35 to 0.58 but the AUC improved only for the experienced reader (0.77 to 0.89, p = 0.005 vs. 0.74 to 0.70, p > 0.05). Sensitivity and NPV improved from 20-30 % to 40-70 %, respectively 88 % to 91-95 %. Specificity and PPV improved only for the experienced reader (87 to 93 % respectively 27 to 63 %).


Adding DWI to T2-MRI improves consistency between readers and has potential to improve readers’ accuracy dependent on his/her experience. DWI could be of additional value, particularly in ruling out CR (high NPV), but considering the sub-optimal PPV one should be cautious about relying solely on MRI for the clinical decision to offer a wait-and-see strategy.

Key Points

• Diffusion-weighted magnetic resonance imaging is increasingly used to assess rectal tumours

• Adding DWI to T2-MRI potentially improves diagnostic accuracy for identifying complete responders

• Adding DWI to T2-MRI improves consistency among readers with different experience levels.

• This combination can help rule out complete tumour response.

• Patients should not be selected for wait-and-see strategies by MRI alone.


Rectal cancer Magnetic resonance imaging Diffusion-weighted imaging Diagnostic accuracy Tumour response Neoadjuvant therapy 


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Copyright information

© European Society of Radiology 2013

Authors and Affiliations

  • S. Sassen
    • 1
    Email author
  • M. de Booij
    • 1
  • M. Sosef
    • 2
  • R. Berendsen
    • 3
  • G. Lammering
    • 4
  • R. Clarijs
    • 5
  • M. Bakker
    • 6
  • R. Beets-Tan
    • 7
  • F. Warmerdam
    • 8
  • R. Vliegen
    • 1
  1. 1.Department of RadiologyAtrium Medical Center ParkstadHeerlenThe Netherlands
  2. 2.Department of General SurgeryAtrium Medical Center ParkstadHeerlenThe Netherlands
  3. 3.Department of Clinical PhysicsAtrium Medical Center ParkstadHeerlenThe Netherlands
  4. 4.Department of Radiation OncologyMAASTRO ClinicMaastrichtThe Netherlands
  5. 5.Department of PathologyAtrium Medical Center ParkstadHeerlenThe Netherlands
  6. 6.Department of Gastroenterology and HepatologyAtrium Medical Center ParkstadHeerlenThe Netherlands
  7. 7.Department of RadiologyMaastricht University Medical CenterMaastrichtThe Netherlands
  8. 8.Department of Internal Medicine/OncologyAtrium Medical Center ParkstadHeerlenThe Netherlands

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