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Morphologic Predictors of Lymph Node Status in Rectal Cancer with Use of High-Spatial-Resolution MR Imaging with Histopathologic Comparison¹

¹ From the University Hospital of Wales and Llandough Hospital NHS Trust, University of Wales College of Medicine, Cardiff. From the 1999 RSNA scientific assembly. Received October 26, 2001; revision requested January 15, 2002; final revision received July 1; accepted August 9. Supported by the NHS Wales Office for Research and Development in Health and Social Care. G.B. supported by a Royal College of Radiologists BUPA research fellowship. Address correspondence to G.B., Department of Radiology, Royal Marsden NHS Trust, Downs Rd, Sutton, Surrey SM2 5PT, England (e-mail: gina.brown@rmh.nthames.nhs.uk).

View larger version (12K): [in a new window]   Figure 1. Histogram shows the number of normal (white bars) and malignant (gray bars) nodes seen on MR images, according to diameter (which is measured in millimeters).

View larger version (79K): [in a new window]   Figure 2. A, T2-weighted fast SE transverse MR image (2,500/100) shows a node of mixed signal intensity with a low-signal-intensity rim (arrowhead). A focus of low signal intensity (arrow) is demonstrated within the predominantly intermediate-signal-intensity node. B, Histologic slice of the corresponding node shows low-signal-intensity rim seen on MR image that corresponds to the normal lymph node capsule (arrowhead). Within the node, there is tumor (arrow) with widespread necrosis in the area corresponding to the low-signal-intensity area seen on the MR image. (Hematoxylin-eosin stain; original magnification, x6.)

View larger version (77K): [in a new window]   Figure 3. A, T2-weighted fast SE transverse MR image (2,500/100) through the upper portion of the rectum. A node with an irregular border (arrow) located close to the right lateral mesorectal margin contains mixed signal intensity. B, Photomicrograph shows corresponding node (arrow) harvested from the right lateral mesorectal margin of the specimen contains proteinaceous extracellular mucin. (Hematoxylin-eosin stain; original magnification, x6.)

View larger version (75K): [in a new window]   Figure 4. A, T2-weighted fast SE transverse MR image (2,500/100) of the lower portion of the rectum. A low-signal-intensity node (arrow) with irregular borders is demonstrated on the left posterolateral border of the mesorectum. B, Corresponding histologic wholemount slice from the total mesorectal excision specimen shows tumor deposit (arrow) with an irregular border within the mesorectum. Since there is no visible nodal tissue, it is indistinguishable from an extranodal deposit. This is classified as node positive with the TNM classification (11). (Hematoxylin-eosin stain; original magnification, x1.)

View larger version (84K): [in a new window]   Figure 5. A, T2-weighted fast SE transverse MR image (>2,500/100) through the middle portion of the rectum. A high-signal-intensity node with smooth borders (arrow) of homogeneous signal intensity is demonstrated close to the right posterolateral border of the mesorectum. B, Corresponding histologic wholemount slice from total mesorectal excision revealed benign node (arrow). (Hematoxylin-eosin stain; original magnification, x1.)

View larger version (17K): [in a new window]   Figure 6. Based on reference 16, graph compares sensitivity and specificity for metastatic nodal detection simultaneously between an assessment of morphology (presence of an irregular border or mixed signal intensity) and node size (defined by a cutoff of >5 mm). Differences in sensitivity and specificity are plotted at the vertical axes at = 1 and = 0, respectively, with confidence limits shown above and below. incorporates the effects of the prevalence of the abnormality and the "costs" of misclassification expressed by relative importance of false-positive and false-negative results. The diagonal line plots how weighting alters the difference in sensitivity and specificity between the two tests. In most applications, the point where the line crosses the horizontal axis would indicate the circumstances under which one test would be regarded as the better one. This chart shows that the whole of the line and its confidence region lie above the horizontal axis, indicating a strong preference for morphologic criteria rather than size, irrespective of prevalence and relative costs.