Intersphincteric resection: MRI for staging

  • Michael UrbanEmail author


With the advance of surgical therapy of rectal carcinoma and improvement of adjuvant therapies the challenges for preoperative staging methods have grown over the last years. The radiologists understanding of rectal carcinoma is constantly evolving. The need of precise staging before operative therapy has lead to refinements in the technique of staging examinations. The election of patients in need of neoadjuvant therapy, reevaluation after therapy, radiation therapy planning and assessment of postoperative changes and recurrence are challenges in the diagnostic workup of patients with rectal cancer. Magnetic resonance imaging (MRI) is now routinely used for preoperative staging of rectal cancer. It provides accurate assessment of the tumor and the surrounding mesorectal fascia as well as precise depiction of important anatomic structures as for example the structures of the pelvic floor and the anal sphincter in tumors of the low rectum. On the other hand evaluation of nodal metastases is still a diagnostic challenge with MRI.


Rectal Cancer Rectal Carcinoma Circumferential Resection Margin External Sphincter Mesorectal Fascia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. [1]
    Beets-Tan RGH, Beets GL (2004) Rectal cancer: Review with emphasis on MR imaging. Radiology 232: 335–346PubMedCrossRefGoogle Scholar
  2. [2]
    Gualdi GF, Casciani E, Guadalaxara A, d’Orta C, Polettini E, Pappalardo G (2000) Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging: comparison with histologic findings. Dis Colon Rectum 43: 338–345PubMedCrossRefGoogle Scholar
  3. [3]
    Maldjian C, Smith R, Kilger A, Schnall M, Ginsberg G, Kochmann M (2000) Endorectal surface coil MR imaging as a staging technique for rectal carcinoma: a comparison study to rectal endosonography. Abdom Imaging 25: 75–80PubMedCrossRefGoogle Scholar
  4. [4]
    Zagoria RJ, Schlarb CA, Ott DJ, et al (1997) Assessment of rectal tumor infiltration utilizing endorectal MR imaging and comparison with endoscopic rectal sonography. J Surg Oncol 64: 312–317PubMedCrossRefGoogle Scholar
  5. [5]
    Hunerbein M, Pegios W, Rau B, Vogl TJ, Felix R, Schlag PM (2000) Prospective comparison of endorectal ultrasound, three dimensional endorectal ultrasound and endorectal MRI in the preoperative evaluation of rectal tumors: preliminary results. Surg Endosc 14: 1005–1009PubMedCrossRefGoogle Scholar
  6. [6]
    Beets-Tan RG, Beets GL, Vliegen RF, et al (2001) Accuracy of magnetic resonance imaging in prediction of tumor-free resection margin in rectal cancer surgery. Lancet 357: 497–504PubMedCrossRefGoogle Scholar
  7. [7]
    Brown G, Kirkham A, Williams GT, et al (2004) High-resolution MRI of the anatomy important in total mesorectal excision of the rectum. AJR Am J Roentgenol 182(2): 431–439PubMedGoogle Scholar
  8. [8]
    MERCURY Study group (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 333: 779CrossRefGoogle Scholar
  9. [9]
    Koh DM, Brown G, Temple L, et al (2005) Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations. Eur Radiol 15: 1650–1657PubMedCrossRefGoogle Scholar
  10. [10]
    Wallengren NO, Holtås S, Andrén Sandberg Å, et al (2000) Rectal carcinoma: double contrast MR imaging for preoperative staging. Radiology 215: 108–114PubMedGoogle Scholar
  11. [11]
    Kim SH, Lee JM, Lee MW, et al (2008) Sonography transmission gel as endorectal contrast agent for tumor visualisation in rectal cancer. AJR 191: 186–189PubMedCrossRefGoogle Scholar
  12. [12]
    Holzer B, Urban M, Hölbling N, Feil W, Novi G, Hruby W, Rosen H, Schiessel R (2003) Magnetic resonance imaging predicts sphincter invasion of low rectal cancer and influences selection of operation. Surgery 133(6): 656–661PubMedCrossRefGoogle Scholar
  13. [13]
    Urban M, Rosen H, Hölbling N, et al (2000) MR-imaging for the preoperative planning of sphincter saving surgery for tumors of the lower third of the rectum: use of intravenous and endorectal contrast materials. Radiology 214: 503–508PubMedGoogle Scholar
  14. [14]
    Okizuka H, Sugimura K, Yoshizako T, Kaj Y, Wada A (1996) Rectal carcinoma: prospective comparison of conventional and gadopentetate dimeglumine enhanced fat-suppressed MR imaging. J Magn Reson Imaging 6(3): 465–471PubMedCrossRefGoogle Scholar
  15. [15]
    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(1): 179–188PubMedCrossRefGoogle Scholar
  16. [16]
    Kim SH, Lee JM, Park HS, et al (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(5): 1093–1101PubMedCrossRefGoogle Scholar
  17. [17]
    Heald RJ, Moran BJ (2008) Embryology and anatomy of the rectum. Semin Surg Oncol 15: 66–71CrossRefGoogle Scholar
  18. [18]
    Jorge JM, Wexner SD (1997) Anatomy and physiology of the rectum and anus. Eur J Surg 163: 723–731PubMedGoogle Scholar
  19. [19]
    Heald RJ, Moran BJ, Brown G, Daniels I (2004) Optimal total mesorectal excision for rectal cancer is in front of Denonvilliers Fascia. Br J Surg 91(1): 121–123PubMedCrossRefGoogle Scholar
  20. [20]
    Church JM, Raudkivi PJ, Hill GL (1987) The surgical anatomy of the rectum — a review with particular relevance to the hazards of rectal mobilisation. Int J Colorectal Dis 2: 158–166PubMedCrossRefGoogle Scholar
  21. [21]
    Goligher JC (ed) (1967) Surgical anatomy and physiology of the colon, rectum and anus. In: Surgery of the anus, rectum and colon, 2nd edn. Bailliere, Tindall&Cassell, London, pp 1–54Google Scholar
  22. [22]
    Kaiser AM, Ortega AE (2002) Anorectal anatomy. Surg ClinN Am 82: 1125–1138CrossRefGoogle Scholar
  23. [23]
    Hussain SM, Stoker J, Lameris JS (1995) Anal sphincter complex: endoanal MR imaging normal anatomy. Radiology 197: 671–677PubMedGoogle Scholar
  24. [24]
    Morren GL, Beets-Tan RG, van Engelshoven JM (2001) Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging. Br J Surg 88: 1506–1512PubMedCrossRefGoogle Scholar
  25. [25]
    Kayshap P, Bates N (2004) Magnetic resonance imaging anatomy of the anal canal. Australasian Radiology 48: 443–449CrossRefGoogle Scholar
  26. [26]
    Murano A, Sasaki F, Kido C, et al (1995) Endoscopic MRI using 3D-spoiled GRASS (SPGR) sequence for local staging of rectal carcinoma. J Comput Assist Tomogr 19(4): 586–591PubMedCrossRefGoogle Scholar
  27. [27]
    Joosten FB, Jansen JB, Joosten HJ, Rosenbusch G (1995) Staging of rectal carcinoma using MR double surface coil, MR endorectal coil, and intrarectal ultrasound: correlation withhistopathologic findings. J ComputAssist Tomogr 19(5): 752–758CrossRefGoogle Scholar
  28. [28]
    Pegios W, Vogl J, Mack MG, et al (1996) MRI diagnosis and staging of rectal carcinoma. Abdom Imaging 21(3): 211–218PubMedCrossRefGoogle Scholar
  29. [29]
    Vogl TJ, Pegios W, Mack MG, et al (1996) Radiological modalities in the staging of colorectal tumors: new perspectives for increasing accuracy. Recent Results Cancer Res 142: 103–120PubMedCrossRefGoogle Scholar
  30. [30]
    Schnall MD, Furth EE, Rosato EF, Kressel HY (1994) Rectal tumor stage: correlation of endorectal MR imaging and pathologic findings. Radiology 190(3): 709–714PubMedGoogle Scholar
  31. [31]
    Okizuka H, Sugimura K, Yoshizako T, Kaji Y, Wada A (1996) Rectal carcinoma: prospective comparison of conventional and gadopentetatedimeglumine enhanced fat-supressed MR imaging. J Magn Res Imaging 6(3): 465–471CrossRefGoogle Scholar
  32. [32]
    Jass JR, Atkin WS, Cuzick J, et al (1986) The grading of rectal cancer: historical perspectives and a multivariate analysis of 447 cases. Histopathology 10(5): 437–459PubMedCrossRefGoogle Scholar
  33. [33]
    Grinnell RS (1939) The grading and prognosis of carcinoma of the colon and rectum. Ann Surg 109: 500–533PubMedCrossRefGoogle Scholar
  34. [34]
    Spratt JA, Spjut HJ (1967) Prevalence and prognosis of carcinoma of the colon and rectum. Cancer 20: 1976–1985PubMedCrossRefGoogle Scholar
  35. [35]
    Cohen AM, Wood WC, Gunderson LL, Shinnar M (1980) Pathological studies in rectalcancer. Cancer 45(12): 2965–2968PubMedCrossRefGoogle Scholar
  36. [36]
    Bjerkeset T, Morild I, Mork S, Soreide O (1987) Tumor characteristics in colorectal cancer and their relationship to treatment and prognosis. Dis Colon Rectum 30(12): 934–938PubMedCrossRefGoogle Scholar
  37. [37]
    Michelassi F, Vannucci L, Montag A, et al (1988) Importance of tumor morphology for the longterm prognosis of rectal adenocarcinoma. Am Surg 54(6): 376–379PubMedGoogle Scholar
  38. [38]
    Sasaki O, Atkin WS, Jass JR (1987) Mucinous carcinoma of the rectum. Histopathology 11(3): 259–272PubMedCrossRefGoogle Scholar
  39. [39]
    Pihl E, Nairn RC, Hughes ES, Cuthbertson AM, Rollo AJ (1980) Mucinous colorectalcarcinoma: immunopathology and prognosis. Pathology 12(3): 439–447PubMedCrossRefGoogle Scholar
  40. [40]
    Secco GB, Fardelli R, Campora E, et al (1994) Primary mucinous adenocarcinomas and signet-ringcell carcinomas of colon and rectum. Oncology 51(1): 30–34PubMedCrossRefGoogle Scholar
  41. [41]
    Kim MJ, Kim WH, Kim NK, et al (1997) Colorectal mucinous carcinoma: findings on MRI. J Comput Assist Tomogr 23:291–296CrossRefGoogle Scholar
  42. [42]
    Hussain SM, Outwater EK, Siegelman ES (1999) Mucinous versus nonmucinous rectal carcinomas: differentiation with MR imaging. Radiology 213: 79–85PubMedGoogle Scholar
  43. [43]
    Cawthorn SJ, Parums DV, Gibbs NM, et al (1990) Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer [see comments]. Lancet 335(8697): 1055–1059PubMedCrossRefGoogle Scholar
  44. [44]
    Merkel S, Mansmann U, Papadopoulos T, et al (2001) The prognostic inhomogeneity of colorectal carcinomas stage III: a proposal for subdivision of Stage III. Cancer 92(11): 2745–2749CrossRefGoogle Scholar
  45. [45]
    Brown B, Radcliffe AG, Newcombe RG, et al (2003) Preoperative assessment of prognostic factors in rectal cancer using high-resolution magnetic resonance imaging. Br J Surg 90(3): 355–364PubMedCrossRefGoogle Scholar
  46. [46]
    Brown G, Richards CJ, Bourne MW, et al (2003) Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 227(2): 371–377PubMedCrossRefGoogle Scholar
  47. [47]
    Adam IJ, Mohamdee MO, Martin IG, et al (1994) Role of circumferential resection margin involvement in the local recurrence of rectal cancer. Lancet 344(8924): 707–711PubMedCrossRefGoogle Scholar
  48. [48]
    Koch M, Kienle P, Antolovic D, Buchler MW, Weitz J (2005) Is the lateral lymph node department relevant? Recent Results Cancer Res 165: 40–45PubMedCrossRefGoogle Scholar
  49. [49]
    Kikuchi R, Takano M, Takagi K, et al (1995) Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines [see comments]. Dis Colon Rectum 38(12): 1286–1295PubMedCrossRefGoogle Scholar
  50. [50]
    Gall FP (1991) Cancer of the rectum — local excision. Int J Colorectal Dis 6(2): 84–85PubMedCrossRefGoogle Scholar
  51. [51]
    Dworak O (1991) Morphology of lymph nodes in the resected rectum of patients with rectal carcinoma. Pathol Res Pract 187(8): 1020–1024PubMedCrossRefGoogle Scholar
  52. [52]
    Brown G, Richards CJ, Bourne MW, et al (2003) Morphologic predictors of lymph node status in rectal cancer with use of high-spatial-resolution MR imaging with histopathologic comparison. Radiology 227(2): 371–377PubMedCrossRefGoogle Scholar
  53. [53]
    Talbot IC, Ritchie S, Leighton MH, et al (1980) The clinical significance of invasion of veins by rectal cancer. Br J Surg 67(6): 439–442PubMedCrossRefGoogle Scholar
  54. [54]
    Horn A, Dahl O, Morild I (1990) The role of venous and neural invasion on survival in rectal adenocarcinoma. Dis Colon Rectum 33(7): 598–601PubMedCrossRefGoogle Scholar
  55. [55]
    Horn A, Dahl O, Morild I (1991)Venous and neural invasion as predictors of recurrence in rectal adenocarcinoma. Dis Colon Rectum 34(9): 798–804PubMedCrossRefGoogle Scholar
  56. [56]
    Smith NJ, Shihab O, Arnaout A, et al (2008) MRI for detection of extramural vascular invasion in rectal cancer. Am J Roentgenol 191: 1517–1522CrossRefGoogle Scholar
  57. [57]
    De Haas-Kock DF, Baeten CG, Jager JJ, et al (1996) Prognostic significance of radial margins of clearance in rectal cancer. Br J Surg 83: 781–785PubMedCrossRefGoogle Scholar
  58. [58]
    Hall NR, Finan PJ, al-Jaberi T, et al (1998) Circumferential margin involvement after mesorectal excision of rectal cancer with curative intent. Predictor of survival but not local recurrence? Dis Colon Rectum 41: 979–983PubMedCrossRefGoogle Scholar
  59. [59]
    Nagtegaal ID, Quirke P (2008) What is the role for the circumferential resection margin in the modern treatment of rectal cancer? J Clin Oncol 28: 303–312CrossRefGoogle Scholar
  60. [60]
    Gosens MJ, Van Krieken JH, Marijnen CA, et al (2007) Improvement of staging by combining tumor and treatment parameters: the value of prognostication in rectal cancer. Clin Gastroenterol Hepatol 5: 997–1003PubMedCrossRefGoogle Scholar
  61. [61]
    Nagtegaal ID, Gosens MJ, Marijnen CA, et al (2007) Combination of tumor and treatment parameters are more discriminative for prognosis than the present TNM system in rectal cancer. J Clin Oncol 25: 1647–1650PubMedCrossRefGoogle Scholar
  62. [62]
    Quirke P, Durdey P, Dixon MF, et al (1986) Local recurrence of adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumor spread and surgical excision. Lancet 2: 996–999PubMedCrossRefGoogle Scholar
  63. [63]
    Birbeck KF, Macklin CP, Tiffin NJ, et al (2002) Rates of circumferential resection margin involvement vary between surgeons and predict outcomes I rectal cancer surgery. Ann Surg 235: 449–457PubMedCrossRefGoogle Scholar
  64. [64]
    Barkhausen J, Quick HH, Lauenstein T (2001) Whole-body MR imaging in 30 seconds with real time true FISP and a continuously rolling table platform: feasibility study. Radiology 220: 252–256PubMedGoogle Scholar
  65. [65]
    Fain SB, Browning FJ, Polzin JA, et al (2004) Floating table isotropic projection (FLIPR) acquisition: a time resolved 3D Intersphincteric resection: MRI for staging 39 method for extended field-of-view MRI during continuous table motion. Magn Res Med 57: 226–232Google Scholar
  66. [66]
    Ludwig U, Sommer G, Zaitsev M, et al (2006) 2D axial moving table acquisitions with dynamic slice adaption. Magn Reson Med 55: 423–430PubMedCrossRefGoogle Scholar
  67. [67]
    Shankaranarayanan A, Herfkens R, Hargreaves BM, et al (2003) Helical MR: continuously moving table axial imaging with radial acquisitions. Magn Res Med 50: 1053–1060CrossRefGoogle Scholar
  68. [68]
    Sommer G, Fautz HP, Ludwig U, et al (2006) Multicontrast sequences with continuous table motion: a novel acquisition technique for extended field of view imaging. Magn Res Med 55: 918–922CrossRefGoogle Scholar
  69. [69]
    Baumann T, Ludwig U, Pache G, et al (2009) Continuously moving table MRI with sliding multislice for rectal cancer staging: image quality and lesion detection. Eur J Radiol 73: 579–587PubMedCrossRefGoogle Scholar
  70. [70]
    Schäfer O, Langer M (2007) Detection of recurrent rectal cancer with CT, MRI and PET/CT. Eur Radiol 17: 2044–2054CrossRefGoogle Scholar
  71. [71]
    Koh DM, Collins DJ (2007) Diffusion weighted imaging in the body: applications and challenges in oncology. Am J Roentgenol 188: 1622–1635CrossRefGoogle Scholar
  72. [72]
    Koh DM, Takahara T, Imai Y, et al (2007) Practical aspects of assessing tumors using clinical diffusion-weighted imaging in the body. Magn Reson Med Sci 6: 211–224PubMedCrossRefGoogle Scholar
  73. [73]
    De Vries 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: 958–965CrossRefGoogle Scholar
  74. [74]
    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
  75. [75]
    Sebag-Montefiore D, Glynne-Jones R, Mortensen N, et al (2005) Pooled analysis of outcome measures including the histopatological R0 resection rate after pre-operative chemoradiation for locally advanced rectal cancer. In: Finan PJ (ed) Tripartite 2005 Colorectal Meeting. Blackwell Publishing, Dublin, Ireland, p 7Google Scholar
  76. [76]
    Burton S, Brown G, Daniels I, et al (2006) MRI identified prognostic features of tumors in distal sigmoid, rectosigmoid, and upper rectum: Treatment with radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 65(2): 445–451PubMedCrossRefGoogle Scholar
  77. [77]
    Williamson PR, Hellinger MD, Larach SW, Ferrara A (1996) Endorectal ultrasound of T3 and T4 rectal cancers after preoperative chemoradiation. Dis Colon Rectum 39(1): 45–49PubMedCrossRefGoogle Scholar
  78. [78]
    Chiari RS, Tyler DS, Anscher MS, et al (1995) Preoperative radiation and chemotherapy in the treatment of adenocarcinoma of the rectum. Ann Surg 221(6): 778–786CrossRefGoogle Scholar
  79. [79]
    Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 336(14): 980–987CrossRefGoogle Scholar
  80. [80]
    Kapiteijn E, Marijnen CA, Nagtegaal ID, et al (2001) Preoperative radiotherapy combined with total mesorectalexcision for resectable rectal cancer. N Engl J Med 345(9): 638–646PubMedCrossRefGoogle Scholar
  81. [81]
    Vliegen RF, Beets GL, Lammering G, et al (2008) Mesorectal fascia invasion after neoadjuvant chemotherapy and radiation therapy for locally advanced rectal cancer: accuracy of MR imaging for prediction. Radiology 246: 454–462PubMedCrossRefGoogle Scholar
  82. [82]
    Dworak O, Keilholz L, Hoffmann A (1997) Pathological features of rectal cancer after preoperative radiochemotherapy. Int J Colorectal Dis 12: 19–23PubMedCrossRefGoogle Scholar
  83. [83]
    Beets Tan RG, Beets GL, Borstlap AC, et al (2000) preoperative assessment of local tumor extent in advanced rectal cancer: CT or high resolution MRI. Abdom Imaging 25: 533–541PubMedCrossRefGoogle Scholar
  84. [84]
    Allen SD, Padhani AR, Dzik-Jurasz AS, et al (2007) Rectal carcinoma: MRI with histologic correlation before and after chemoradiation therapy. AJR Am J Roentgenol 188: 442–451PubMedCrossRefGoogle Scholar
  85. [85]
    Brown G, Richards GJ, Newcombe RG, et al (1999) Rectal carcinoma: thin sectionMRimaging for staging in 28 patients. Radiology 2121: 215–222Google Scholar
  86. [86]
    Chen CC, Lee RC, Lin JK, et al (2005) How accurate is magnetic resonance imaging in restaging rectal cancer in patients receiving preoperative combined chemoradiotherapy? Dis Colon Rectum 48: 722–728PubMedCrossRefGoogle Scholar
  87. [87]
    Peschaud F, Cuenod CA, Benoist S, et al (2005) Accuracy of magnetic resonance imaging in rectal cancer depends on location of the tumor. Dis Colon Rectum 8: 1603–1609CrossRefGoogle Scholar

Copyright information

© Springer-Verlag/Wien 2012

Authors and Affiliations

  1. 1.Institute of Radiology, Danube HospitalVienna Ludwig Boltzmann Institute for Digital Radiography and Interventional RadiologyViennaAustria

Personalised recommendations