Rectal MRI (an approach)

Last revised by Arlene Campos on 13 May 2024

Rectal MRI is a key imaging investigation in the diagnosis, staging and follow up of rectal cancer. An increase in the utility of rectal MRI as been driven by the recognition of the mesorectum as a distinct anatomic compartment containing and limiting the margins of the rectum, and forming a surgical target to enable complete removal of the tumor and associated nodes en bloc. Several parameters need to be reviewed and reported on, and the emphasis on which factors are important has altered with emerging evidence.

The approach below takes recommendations from various major working groups and societies 1-4, as well as personal experiences, into consideration. The key reporting parameters described below may form the basis of a template report.

The request should indicate biopsy confirmation of rectal malignancy, usually obtained via endoscopy, and the size of the tumor. It should also indicate the distance relative to the anal verge. MRI is usually not undertaken for tumors for which the distal edge is more than 15 cm from the anal verge.

Standardized imaging acquisition is important. A combination of T2 and DWI sequences are employed for staging and restaging. There is no role for T1 weighted imaging, with post-contrast T1 weighted imaging reserved for imaging of recurrent rectal cancers in order to plan pelvic exenteration. Please see the article on rectal cancer MRI protocol for more details.

  • the sagittal T2 images are used to plan the small field-of-view axial and coronal images, which enable accurate determination of the tumor's relationship to the muscularis propria and the mesorectal fascia

  • check that the axial and coronal images are truly perpendicular and parallel to the path of the rectum bearing the tumor

  • when the tumor traverses a part of the rectum that is not truly straight, it is necessary to acquire further sets of axial and coronal images

  • the risk of incorrect setting of the planes is volume averaging leading to unsharpness of the muscularis propria being misinterpreted as tumor transgression through the muscularis propria, essentially an upstaging of disease

  • the length of the tumor is measured, either on the sagittal or coronal images

  • the distance from the distal edge to the anorectal junction is measured; this is approximately the site where the angle between the rectum and anal canal is identified

  • the distance from the distal edge of the tumor to the anal verge is measured

  • the definition of whether a tumor is in the low, mid or upper rectum is widely variable and multiple proposals co-exist

  • the upper limit of the rectum is recognized as the sigmoid take-off on a sagittal image as the point at which the bowel travels anteriorly away from the sacrum 10

  • the morphology is described as circumferential or annular, semi-annular, or polypoid

  • semi-annular tumors typically have bulky edges which are the heaped margins of the outer edge of the tumor mass, and the invasive front will be between these edges and described using a clockface terminology

  • the relationship of the tumor to the anterior peritoneal reflection is also described; the reflection is off the upper part of the rectum and below this level the rectum is extraperitoneal and the margin of excision is the mesorectal fascia

  • nodular extension through the muscularis propria, contiguous with the luminal tumor, is defined as tumor achieving T3 status according to the TNM classification

  • low signal spicules are not tumor but small fibrous strands or vessels

  • tumor extending to make contact with the peritoneal reflection or other organs are defined as T4a or T4b respectively

  • where tumor contacts (less than 1 mm distance) the mesorectal fascia, the circumferential resection margin is said to be involved or threatened

  • the same principle applies for tumor deposits, but not lymph nodes which have a smooth outer margin

  • remember that the CRM is not mentioned if the tumor lies in a peritonealised portion of the rectum

  • tumor signal tissue extending in a serpiginous manner alongside the rectum represents tumor in vessel, known as extramural venous invasion, a risk factor and predictor for metastatic disease

  • irregularly marginated nodules of tissue along the path of the vessels represent tumor deposits, an entity that confers high risk and said to be more important than mesorectal lymph nodes due to the fact that TDs occur via hematogenous spread

  • unlike in other parts of the body, the primary means of identifying abnormal mesorectal nodes is by signal and contour heterogeneity, rather than size

  • a quirk of the current TNM staging system (TNM 8) is that tumor deposits, which are now known to confer a greater risk than involved nodes, present a category of N1c, less than if there were no TDs but many nodes

  • pelvic sidewall nodes are considered by some to be part of the local nodal spread and therefore counted within the N system, but by many to be metastatic and therefore counted as M1

  • mucinous cancers 8 are recognized due to their higher signal intensity on T2 imaging, with a preponderance for local perforation and a less optimal response to chemoradiation

  • the anatomy of the low rectum means that tumors that have penetrated the muscularis propria by even 1 mm may lie very close to the adjacent levator muscle as it turns into the external sphincter, and a conventional surgical resection plane that follows the mesorectal fascia may lead to cutting through tumor and a risk of a local recurrence

  • these tumors, if surgically treated, are managed by operations with larger tissue resections such as AP resection or extralevator AP resection (ELAPE)

  • a detailed guide to analyzing post-chemoradiation MRI rectal studies is presented here

  • appearances vary due to a combination of fibrosis, edema and mucinous degeneration of tumor

  • if the imaging suggests a near/complete response such as with the split scar sign, endoscopy must be performed to visualize and biopsy the scar to confirm response

Suggested items to include in a template report, based on the above pieces of data, are 2, 4:

  • length of tumor

  • distance from distal edge of tumor to anorectal junction

  • distance from distal edge of tumor to anal verge

  • tumor relationship to peritoneal reflection (above/straddling/below)

  • tumor morphology (annular/semi-annular/polypoid)

  • invasive margins (clock face terminology)

  • T stage (and which organs involved if T4b)

  • depth of tumor invasion (less or greater than 5 mm)

  • shortest distance to mesorectal fascia or levator muscle

  • extramural venous invasion

  • tumor deposits

  • mesorectal lymph nodes

  • extramesorectal lymph nodes

  • for low cancers, involvement of anal sphincter muscles or intersphincteric fat

  • summary stage: longitudinal and axial location, T, N, EMVI, TD, CRM

  • ensure that the small field-of-view axial and coronal images are truly perpendicular and parallel to the plane of the portion of the rectum bearing the tumor, or else the T stage may be overestimated

  • for low tumors, describe the relationship of tumor to the levator muscle complex and anal sphincters as this may determine the surgical approach to ensure clearance as a standard total mesorectal excision may not deliver a complete resection

  • remember the anatomy of the peritoneum when describing whether a margin is threatened - only the lower third of the rectum is completely non-peritonealised

  • identify the key parameters that define risk - low cancers, T stage, depth of invasion of tumor through muscularis propria, CRM status, EMVI and tumor deposits

  • MRI is generally poor at determining whether lymph nodes are involved, and the importance of lymph node involvement when fully contained within the mesorectal compartment has been questioned by recent evidence

  • when restaging tumors following chemoradiation, a variety of appearances may be seen due to the combination of fibrosis, edema and mucinous degeneration, but endoscopic review of the tumor site is essential to confirm complete response

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