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MRI in rectal cancer

Doc dr Nataša Prvulović Bunović, radiologist,

Diagnostic imaging Centre,
Oncology Institute of Vojvodina
Sremska Kamenica,

* Why MRI ?
** Normal MR Anatomy
*** Preoperative Staging
**** Post Treatment and Recurrence Evaluation
**** Conclusion


Endorectal US (ERUS) has high accuracy in rectal
cancer staging, but several important limitations
opponent to MRI

* Small or Very large tumors

* Very High or Very Low Mass
* Stenotic Cancer
* Mesorectal Fascia
* LN evaluation
*** MRI is performed sans ER device
*inferior contrast resolution
Diagnostic tests and imaging

History Diagnostic imaging:

Clinical exam - digital delineation
exam local staging TNM
follow up
Barium enema-

Biopsy + PH

MRI protocol
3 plane MRI slices

sagital T2W TSE

axial T2W TSE FOV (5mm)

high resolution T2W TSE
coronal T2W TSE
*without contrast and without FS
Patient preparation and MR scanning

* Exam is performed with patient lying on the back, with

phased array coil, intravaginal/endorectal coil optional

* Painless, with no proven adversed biological effects, demands


* Duration time 20-45’

* No special preparation, suggested fasting for 6 hours prior to

exam, urination 2-3 hours prior to exam

* IM application of spasmolytics (optional)

Colon cancer staging

• Staging of colon cancer is an important indication for the type of treatment

• Several factors are important: age, general health, family history of
cancer, other medical conditions.
• CA: localization, histological type/grade, TNM stage
The role of MRI in rectal cancer

• MRI has to determine the following:

• Location of the tumor
Is it a low or high rectal tumor, what is the size, circumferential growth?
• T-stage: T1, T2, T3 or T4
• Distance of the tumor to the mesorectal fascia. Is it threatened or
• Tumor growth or lymph nodes within 1 mm of the resection margin?
• N-stage: Are there any lymph nodes within the mesorectum or beyond the
Main question *T3 or not T3*
MR protocol on Oncology Institute of Vojvodina
Mesorectal fascia and TME

•The mesorectal fat has a high signal

intensity on T1/T2W
The mesorectal fat is bounded by the
mesorectal fascia, which is seen as a fine line
of low signal intensity (pink arrows).
• In a TME the mesorectal fascia is the
resection plane.
•The shortest distance from the tumor or
lymph nodes to the mesorectal fascia is called
the cirumferential resection margin (CRM).

Preparation for rectal MRI

clisma+ spasmolytic i.m.

• T2W ax and sag

• T1W cor

•The cancer is limited to mucosa app

95% of patients with stage I
colorectal cancers are cured by
surgery alone.

• The cancer has grown through the wall of the colon

and may extend into nearby tissue,but has not
spread to the lymph nodes.

• Surgery is usually the only treatment needed for

colon cancer but RT or HT may be needed as
additional therapy
Stage II

T2W sag and ax

Stage III

T3 CRM+ N1
T3 CRM -

Infiltration of perirectal fat

Short course RT + TME

CRM + <1mm

CRM – >1mm

The shortest distance between

tumor to the mesorectal fascia is
the most powerful predictor for
local recurrence.
t3T3 CRM +

T1W ax

T2W ax
Infiltration of MRF
With lymph node involvement
Long course RT +HT than TME

If the distance is > 2mm the mesorectal fascia is not threatened.

Stage III T3N1Mo

T1W cor T2W ax

• The cancer has spread to nearby lymph nodes, but not to other organs
• Surgery is the first treatment, followed by chemotherapy or RT depending on the
size and localization of the tumor.
Stage IV

Loc. rec. Sag and ax T2W

The cancer has spread to distant organs and tissues.

TH: depending on the extent of the tumor's spread,
Chemotherapy is initial therapy may be followed with surgery/RT.
Stage IV

ax an sag T2W

The cancer has spread to distant organs and tissues.

TH: depending on the extent of the tumor's spread,
Chemotherapy is initial therapy may be followed with surgery/RT.
Regional spread of rectal cancer
Follow up after therapy

• Downstaging
• Downsizing
• Same stage
• Upstaging
• Upsizing
Before and after therapy
MRI after RT

T2 sag and ax after RT T2 ax ↓ Vol Ca decrease

MRI before and after RT

T3No ToNo

T2 ax before and after RT, CRP

*complete pathological response (CPR) in 3-5%, of ptc + HT in 15-30%
Follow up and detection of reccurence

MRI is the best imaging modality for detection of rectal CA recc.

1. y 50%
2. y 80%
First 4y 93%

MRI follow up :

2-3 months after surgery

every 6 months in 2y from surgery
in borderline findings or susup. findings on 3m
after 4y form surgery 1/y
Res. recti ant. cum Stapler pp. Ca aa.
Stenosis of anastom. at from AK
PH: benign , fibrosis
St post pp./ sec Milles am X
CT: recurrence
MRI: complex fibrosis with fistula
Large mass arising from the cervix
involving the uterine body, rectum and bladder.
Figo IV
Aftifacts = Problems

Due to irregular breathing

Patient movement
Bowel peristalsis
Rarely: blood vessel’s pulsations
Take home message

T2W sagi, ax
* The two major advancements in the treatment of rectal
cancer are total mesorectal excision (TME)
and neoadjuvant radiotherapy and chemotherapy.
* Both have dramatically changed the local recurrence
and survival rates. MRI is the most accurate tool for
the local staging of rectal cancer and is a powerful tool
to select the appropriate treatment-

* The decision whether a patient with rectal cancer

is a candidate for TME only or neoadjuvanttherapy
followed by TME, is made on the findings on MRI.