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Rectal cancer pelvic recurrence: imaging patterns and key concepts to guide treatment planning

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Abstract

For rectal cancer, MRI plays an important role in assessing extramural tumor spread and informs surgical planning. The contemporary standardized management of rectal cancer with total mesorectal excision guided by imaging-based risk stratification has dramatically improved patient outcomes. Colonoscopy and CT are utilized in surveillance after surgery to detect intraluminal and extramural recurrence, respectively; however, local recurrence of rectal cancer remains a challenge because postoperative changes such as fat necrosis and fibrosis can resemble tumor recurrence; additionally, mucinous adenocarcinoma recurrence may mimic fluid collection or abscess on CT. MRI and 18F-FDG PET are problem-resolving modalities for equivocal imaging findings on CT. Treatment options for recurrent rectal cancer include pelvic exenteration to achieve radical (R0 resection) resection and intraoperative radiation therapy. After pathologic diagnosis of recurrence, imaging plays an essential role for evaluating the feasibility and approach of salvage surgery. Patterns of recurrence can be divided into axial/central, anterior, lateral, and posterior. Some lateral and posterior recurrence patterns especially in patients with neurogenic pain are associated with perineural invasion. Cross-sectional imaging, especially MRI and 18F-FDG PET, permit direct visualization of perineural spread, and contribute to determining the extent of resection. Multidisciplinary discussion is essential for treatment planning of locally recurrent rectal cancer. This review article illustrates surveillance strategy after initial surgery, imaging patterns of rectal cancer recurrence based on anatomic classification, highlights imaging findings of perineural spread on each modality, and discusses how resectability and contemporary surgical approaches are determined based on imaging findings.

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Authors and Affiliations

  1. Department of Radiology, Mayo Clinic, Rochester, USA

    Akitoshi Inoue, Shannon P. Sheedy, Michael L. Wells, Achille Mileto, Ajit H. Goenka, Eric C. Ehman, Mariana Yalon, Naveen S. Murthy & Joel G. Fletcher

  2. Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan

    Akitoshi Inoue

  3. Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, USA

    Kellie L. Mathis, Kevin T. Behm & Sherief F. Shawki

  4. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA

    David H. Bruining

  5. Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, USA

    Rondell P. Graham

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  1. Akitoshi Inoue
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Correspondence to Akitoshi Inoue.

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Conflict of interest

Achille Mileto—Consultant for Bayer Healthcare. Ajit H. Goenka— Others: Research grant from the Champions for Hope Pancreatic Cancer Research Program of the Funk-Zitiello Foundation; Advance the Practice Award from the Department of Radiology, Mayo Clinic, Rochester, Minnesota; CA190188, Department of Defense (DoD), Office of the Congressionally Directed Medical Research Programs (CDMRP); R01CA256969, National Cancer Institute (NCI) of the National Institutes of Health (NIH); Institutional research grant from Sofie Biosciences; Advisory Board (ad hoc), BlueStar Genomics. David H. Bruining– Consulting: Medtronics and Janssen; Research support: Medtronics and Takeda; Helmsley Charitable Trust (grants to institution). Joel G. Fletcher—Siemens Healthcare GmbH (grant to institution); Helmsley Charitable Trust (grants to institution); Pfizer (grant to institution); Boehringer Ingelheim (consulting to institution); Takeda (consulting to institution); Janssen (consulting to institution); Glaxo Smith Kline (consulting to institution). For the remaining authors – none were declared.

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Inoue, A., Sheedy, S.P., Wells, M.L. et al. Rectal cancer pelvic recurrence: imaging patterns and key concepts to guide treatment planning. Abdom Radiol 48, 1867–1879 (2023). https://doi.org/10.1007/s00261-022-03746-4

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