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Rectal Cancer: Review with Emphasis on MR Imaging¹

¹ From the Departments of Radiology (R.G.H.B.T.) and Surgery (G.L.B.), University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, the Netherlands. Received October 25, 2002; revision requested December 27; final revision received April 24, 2003; accepted May 20; updated November 26. Address correspondence to R.G.H.B.T. (e-mail: rbe@rdia.azm.nl).

View larger version (149K): [in a new window]   Figure 1. Magnetic resonance (MR) imaging anatomy of the mesorectum and the mesorectal fascia. Transverse T2-weighted turbo spin-echo (repetition time msec/echo time msec, 3,427/150; field of view 20 x 20 cm; matrix 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image of rectum and mesorectum. Mesorectum consists of rectum (arrows) and surrounding mesorectal fat (*) with perirectal lymph nodes. It is enveloped by the thin mesorectal fascia (arrowheads).

View larger version (127K): [in a new window]   Figure 2. Transverse contrast material-enhanced CT scan in a 62-year-old man with rectal cancer shows rectal tumor (arrows) limited to the mesorectum. It is difficult to accurately predict on the basis of CT scans whether tumor is limited to (T2) or has just breached the rectal wall (T3). Owing to inherent low contrast and spatial resolution of conventional CT techniques, the muscular rectal wall cannot be clearly delineated.

View larger version (167K): [in a new window]   Figure 3a. T2-stage rectal cancer overstaged at MR imaging as a T3-stage tumor in a 67-year-old woman. (a) Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows almost-circumferential rectal cancer (white arrow). Because of transmural stranding from tumor into perirectal fat (arrowheads), this tumor was staged T3. Mesorectal fascia (black arrows) is clearly depicted. CRM of more than 10 mm was predicted. (b) Corresponding microscopy section demonstrates tumor (black arrows) limited to the rectal wall (white arrow). Spiculations consisted of desmoplastic reaction alone (arrowheads), with no tumor cells. (Hematoxylin-eosin stain; original magnification, x25.) (Reprinted, with permission, from reference 64.)

View larger version (176K): [in a new window]   Figure 3b. T2-stage rectal cancer overstaged at MR imaging as a T3-stage tumor in a 67-year-old woman. (a) Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows almost-circumferential rectal cancer (white arrow). Because of transmural stranding from tumor into perirectal fat (arrowheads), this tumor was staged T3. Mesorectal fascia (black arrows) is clearly depicted. CRM of more than 10 mm was predicted. (b) Corresponding microscopy section demonstrates tumor (black arrows) limited to the rectal wall (white arrow). Spiculations consisted of desmoplastic reaction alone (arrowheads), with no tumor cells. (Hematoxylin-eosin stain; original magnification, x25.) (Reprinted, with permission, from reference 64.)

View larger version (181K): [in a new window]   Figure 4a. T3-stage rectal cancer in a 70-year-old man. (a) Transverse contrast material-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR image shows rectal tumor (black arrow) with transmural stranding (arrowheads) in mesorectal fat. Tumor stage was determined at MR imaging as T3. On the basis of MR images, a wide tumor-free CRM of more than 5 mm was predicted. Mesorectal fascia (white arrows) is clearly depicted. (b) Corresponding resection specimen shows T3-stage tumor (white arrows) has penetrated the rectal wall. Spiculations consist of desmoplastic reactions (arrowheads) containing tumor cells (black arrows). CRM was measured as 6 mm. (Hematoxylin-eosin stain; original magnification, x25.) (Reprinted, with permission, from reference 64.)

View larger version (161K): [in a new window]   Figure 4b. T3-stage rectal cancer in a 70-year-old man. (a) Transverse contrast material-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR image shows rectal tumor (black arrow) with transmural stranding (arrowheads) in mesorectal fat. Tumor stage was determined at MR imaging as T3. On the basis of MR images, a wide tumor-free CRM of more than 5 mm was predicted. Mesorectal fascia (white arrows) is clearly depicted. (b) Corresponding resection specimen shows T3-stage tumor (white arrows) has penetrated the rectal wall. Spiculations consist of desmoplastic reactions (arrowheads) containing tumor cells (black arrows). CRM was measured as 6 mm. (Hematoxylin-eosin stain; original magnification, x25.) (Reprinted, with permission, from reference 64.)

View larger version (37K): [in a new window]   Figure 5. Schematic of CRM versus T stage. The most powerful predictor for local recurrence is the shortest distance from tumor to mesorectal fascia (ie, the CRM) (double-headed arrows). The problem with the present T-staging system is that it does not discriminate between tumors with a wide CRM (T3) and tumors with a close or involved resection margin (T3*). Although they have the same T stage, both groups have different risks for recurrence and require different treatment strategies. It would, therefore, be more important to be able to identify on images those bulky tumors that will have a close or involved resection margin than to predict the exact T stage of the tumor. T1 = T1-stage tumor, T2 = T2-stage tumor, T4 = T4-stage tumor, Ves = vesicula, Ves Sem. = vesicula seminalis.

View larger version (179K): [in a new window]   Figure 6a. T3-stage rectal cancer with involved mesorectal resection plane in a 73-year-old man. (a) Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows bulky T3-stage tumor in anterior rectal wall (white arrows) extending to mesorectal fascia (black arrows). CRM was, therefore, predicted to be 0 mm. (b) Corresponding resection specimen confirms that tumor (thin arrows) has indeed invaded mesorectal fascia (thick arrows) and that the CRM is 0 mm. Patient had widespread metastatic disease and underwent palliative resection of the primary tumor. (Hematoxylin-eosin stain; original magnification, x25.)

View larger version (184K): [in a new window]   Figure 6b. T3-stage rectal cancer with involved mesorectal resection plane in a 73-year-old man. (a) Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows bulky T3-stage tumor in anterior rectal wall (white arrows) extending to mesorectal fascia (black arrows). CRM was, therefore, predicted to be 0 mm. (b) Corresponding resection specimen confirms that tumor (thin arrows) has indeed invaded mesorectal fascia (thick arrows) and that the CRM is 0 mm. Patient had widespread metastatic disease and underwent palliative resection of the primary tumor. (Hematoxylin-eosin stain; original magnification, x25.)

View larger version (195K): [in a new window]   Figure 7a. T3-stage rectal mucinous adenocarcinoma with involved mesorectal resection plane in a 55-year-old man. (a) Transverse and (b) coronal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show hyperintense rectal tumor (arrowheads) extending to mesorectal excision plane on anterior and left lateral sides (arrows). The hyperintense nature of the lesion on T2-weighted images is characteristic of mucinous tumor. On the basis of MR findings, the patient was selected for a long course of radiation therapy before surgery. Mucinous adenocarcinoma was confirmed at histologic examination.

View larger version (208K): [in a new window]   Figure 7b. T3-stage rectal mucinous adenocarcinoma with involved mesorectal resection plane in a 55-year-old man. (a) Transverse and (b) coronal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show hyperintense rectal tumor (arrowheads) extending to mesorectal excision plane on anterior and left lateral sides (arrows). The hyperintense nature of the lesion on T2-weighted images is characteristic of mucinous tumor. On the basis of MR findings, the patient was selected for a long course of radiation therapy before surgery. Mucinous adenocarcinoma was confirmed at histologic examination.

View larger version (202K): [in a new window]   Figure 8a. T4-stage rectal cancer with fixation to dorsal vaginal wall in a 61-year-old woman. (a) Sagittal and (b) transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show distal rectal tumor in anterior (white arrows) and dorsal (black arrows) parts of the rectal wall. Tumor has penetrated mesorectal fascia anteriorly and invaded the dorsal vaginal wall (arrowheads). Hyperintense lesion in left pubic bone is a cyst. On the basis of these images, the patient was selected for a long course of radiation therapy before extensive surgery.

View larger version (194K): [in a new window]   Figure 8b. T4-stage rectal cancer with fixation to dorsal vaginal wall in a 61-year-old woman. (a) Sagittal and (b) transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show distal rectal tumor in anterior (white arrows) and dorsal (black arrows) parts of the rectal wall. Tumor has penetrated mesorectal fascia anteriorly and invaded the dorsal vaginal wall (arrowheads). Hyperintense lesion in left pubic bone is a cyst. On the basis of these images, the patient was selected for a long course of radiation therapy before extensive surgery.

View larger version (198K): [in a new window]   Figure 9a. T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show T4-stage rectal cancer with (a) prostate and (b) ureteral invasion. (a) Transverse image in a 65-year-old man shows distal rectal tumor (arrows) with involvement of left lobe of prostate. Normally hyperintense left peripheral zonal anatomy shows low signal intensity due to tumor invasion (arrowheads) from rectal cancer, as confirmed at biopsy. (b) Sagittal image in a 67-year-old man shows distal ureteral stenosis (arrowheads) caused by desmoplastic reaction from rectal tumor (white arrows) and consequent proximal dilatation of left ureter (black arrows).

View larger version (196K): [in a new window]   Figure 9b. T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images show T4-stage rectal cancer with (a) prostate and (b) ureteral invasion. (a) Transverse image in a 65-year-old man shows distal rectal tumor (arrows) with involvement of left lobe of prostate. Normally hyperintense left peripheral zonal anatomy shows low signal intensity due to tumor invasion (arrowheads) from rectal cancer, as confirmed at biopsy. (b) Sagittal image in a 67-year-old man shows distal ureteral stenosis (arrowheads) caused by desmoplastic reaction from rectal tumor (white arrows) and consequent proximal dilatation of left ureter (black arrows).

View larger version (166K): [in a new window]   Figure 10a. (a) Transverse and (b) sagittal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images of T4-stage rectal cancer with fixation to dorsal wall of the bladder. (a) Strongly hyperintense tumor mass (black arrows) in a 79-year-old man extends from rectal wall into dorsal wall of the bladder. The mass has clearly penetrated the bladder wall, causing complete disruption of the muscular layer (white arrows). High signal intensity of the tumor suggests adenocarcinoma of the mucinous type, which was confirmed at histologic examination, as was bladder involvement. (b) Bladder wall invasion (arrows) from rectal cancer in a 67-year-old man. In contrast to the tumor in a, the mass is only slightly hyperintense relative to normal hypointense rectal wall (arrowheads). This is the typical MR appearance of nonmucinous type of rectal adenocarcinoma.

View larger version (185K): [in a new window]   Figure 10b. (a) Transverse and (b) sagittal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR images of T4-stage rectal cancer with fixation to dorsal wall of the bladder. (a) Strongly hyperintense tumor mass (black arrows) in a 79-year-old man extends from rectal wall into dorsal wall of the bladder. The mass has clearly penetrated the bladder wall, causing complete disruption of the muscular layer (white arrows). High signal intensity of the tumor suggests adenocarcinoma of the mucinous type, which was confirmed at histologic examination, as was bladder involvement. (b) Bladder wall invasion (arrows) from rectal cancer in a 67-year-old man. In contrast to the tumor in a, the mass is only slightly hyperintense relative to normal hypointense rectal wall (arrowheads). This is the typical MR appearance of nonmucinous type of rectal adenocarcinoma.

View larger version (170K): [in a new window]   Figure 11a. MR imaging is superior to CT for prediction of uterine invasion from rectal tumor. (a) Transverse contrast-enhanced CT scan shows tumor mass (arrows) in central part of the pelvis of a 52-year-old-woman. Mass was diagnosed at CT as involving rectum and uterus, but it is hard to predict tumor origin because tumor, uterus, and rectum cannot be easily delineated. (b) Sagittal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image in same patient clearly shows that tumor originates from the rectum (black arrows). Although tumor extends on the dorsal wall to the presacral fascia (arrowheads), on the ventral wall it is limited to the rectal wall. Hypointense line (white arrows) between tumor and uterus is a composition of uterine wall, peritoneum, mesorectal fascia, and rectal wall and indicates that tumor has not yet invaded the uterine body, in contrast to the findings suggested at CT.

View larger version (192K): [in a new window]   Figure 11b. MR imaging is superior to CT for prediction of uterine invasion from rectal tumor. (a) Transverse contrast-enhanced CT scan shows tumor mass (arrows) in central part of the pelvis of a 52-year-old-woman. Mass was diagnosed at CT as involving rectum and uterus, but it is hard to predict tumor origin because tumor, uterus, and rectum cannot be easily delineated. (b) Sagittal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image in same patient clearly shows that tumor originates from the rectum (black arrows). Although tumor extends on the dorsal wall to the presacral fascia (arrowheads), on the ventral wall it is limited to the rectal wall. Hypointense line (white arrows) between tumor and uterus is a composition of uterine wall, peritoneum, mesorectal fascia, and rectal wall and indicates that tumor has not yet invaded the uterine body, in contrast to the findings suggested at CT.

View larger version (153K): [in a new window]   Figure 12a. MR imaging is superior to CT for prediction of pelvic wall involvement from locally recurrent rectal cancer. (a) Transverse contrast-enhanced CT scan shows mass (arrows) in left lower pelvis of a 66-year-old man who underwent resection of rectal cancer 2 years previously. Diagnosis of local recurrence was made on the basis of involvement of left piriform muscle (arrowheads) and was confirmed at biopsy. (b) Coronal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image in same patient clearly shows that tumor (black arrows) does not invade the left piriform muscle. An intact fat plane is still seen between tumoral and muscle tissues (white arrows). Multiplanar imaging capability and superior soft-tissue contrast resolution of MR allow more confident diagnosis of the exact extent of tumor invasion into surrounding structures.

View larger version (197K): [in a new window]   Figure 12b. MR imaging is superior to CT for prediction of pelvic wall involvement from locally recurrent rectal cancer. (a) Transverse contrast-enhanced CT scan shows mass (arrows) in left lower pelvis of a 66-year-old man who underwent resection of rectal cancer 2 years previously. Diagnosis of local recurrence was made on the basis of involvement of left piriform muscle (arrowheads) and was confirmed at biopsy. (b) Coronal T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image in same patient clearly shows that tumor (black arrows) does not invade the left piriform muscle. An intact fat plane is still seen between tumoral and muscle tissues (white arrows). Multiplanar imaging capability and superior soft-tissue contrast resolution of MR allow more confident diagnosis of the exact extent of tumor invasion into surrounding structures.

View larger version (146K): [in a new window]   Figure 13a. MR imaging is superior to CT for prediction of pelvic wall involvement from local recurrent rectal cancer. (a) Transverse contrast-enhanced CT scan shows enhancing mass (arrow) in presacral space in a 55-year-old man who underwent resection of rectal cancer 1 years previously. Diagnosis of local recurrence was confirmed at biopsy. At CT, the exact extent (arrowheads) of tumor into right piriform muscle was difficult to predict. (Reprinted, with permission, from reference 79.) (b) Transverse contrast-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR image in same patient more clearly shows enhancing tumor mass (arrows) and its exact extent into piriform muscle tissue (arrowheads). On the basis of this MR study, accurate planning of anticipated resection planes was performed before curative surgery.

View larger version (154K): [in a new window]   Figure 13b. MR imaging is superior to CT for prediction of pelvic wall involvement from local recurrent rectal cancer. (a) Transverse contrast-enhanced CT scan shows enhancing mass (arrow) in presacral space in a 55-year-old man who underwent resection of rectal cancer 1 years previously. Diagnosis of local recurrence was confirmed at biopsy. At CT, the exact extent (arrowheads) of tumor into right piriform muscle was difficult to predict. (Reprinted, with permission, from reference 79.) (b) Transverse contrast-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR image in same patient more clearly shows enhancing tumor mass (arrows) and its exact extent into piriform muscle tissue (arrowheads). On the basis of this MR study, accurate planning of anticipated resection planes was performed before curative surgery.

View larger version (188K): [in a new window]   Figure 14a. Transverse contrast-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR images of rectal cancer with involved nodes in mesorectal fat. (a) Rectal tumor (arrows) with involved perirectal nodes (arrowheads) are all located within the mesorectum in a 69-year-old woman. (b) Rectal tumor (arrows) with involved perirectal nodes (arrowheads) are located within mesorectum in a 70-year-old man. Mesorectum is enveloped by mesorectal fascia. In TME, the entire mesorectum is removed, including fascia and nodes.

View larger version (195K): [in a new window]   Figure 14b. Transverse contrast-enhanced T1-weighted turbo spin-echo (612/15; field of view, 20 x 15 cm; matrix, 512 x 384; echo train length, five; number of signals acquired, six; section thickness, 4 mm) MR images of rectal cancer with involved nodes in mesorectal fat. (a) Rectal tumor (arrows) with involved perirectal nodes (arrowheads) are all located within the mesorectum in a 69-year-old woman. (b) Rectal tumor (arrows) with involved perirectal nodes (arrowheads) are located within mesorectum in a 70-year-old man. Mesorectum is enveloped by mesorectal fascia. In TME, the entire mesorectum is removed, including fascia and nodes.

View larger version (163K): [in a new window]   Figure 15. Rectal cancer with involved lateral node outside mesorectum. Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows enlarged, round, hyperintense lymph node (arrowheads) in left hypogastric region in a 54-year-old man with rectal cancer, suggestive of a metastatic node. This node is located outside the mesorectum, and with standard TME it would be left behind. Such nodal involvement can be a risk for local recurrence, as illustrated in Figure 16.

View larger version (167K): [in a new window]   Figure 16. Recurrent rectal cancer in left hypogastric region in a 66-year-old man. Transverse T2-weighted turbo spin-echo (3,427/150; field of view, 20 x 20 cm; matrix, 256 x 179; echo train length, 25; number of signals acquired, eight; section thickness, 4 mm) MR image shows tumor mass (arrows) that is slightly hyperintense compared with hypointense muscle tissue in patient previously treated with TME for rectal cancer. No imaging had been performed before primary surgery. This MR finding is highly suggestive of local recurrence from nodal metastasis outside the mesorectal plane, in the left hypogastric region. The patient underwent curative resection of the recurrent tumor, and surgical and histologic findings confirmed the nodal origin of this recurrence.