J Korean Soc Radiol.  2019 May;80(3):425-444. 10.3348/jksr.2019.80.3.425.

Radiologic Report for Magnetic Resonance Imaging of Rectal Cancer before Treatment

• Park BG
• Cho SH

• KMID: 2454024
• DOI: http://doi.org/10.3348/jksr.2019.80.3.425

Abstract

Modern management of rectal cancer highly depends on the interpretation of high-spatial-resolution MRI, which determines the benefits from preoperative chemoradiotherapy or surgery alone. Accordingly, the baseline MRI report plays a pivotal role in planning the treatment. Although several structured reporting templates for rectal cancer staging on MRI are available, many radiologists still use the free-text format. In this review, we discuss the essential items for reporting rectal cancer on MRI before treatment to guide general radiologists in preparing a qualified report.

MeSH Terms

Chemoradiotherapy
Magnetic Resonance Imaging*
Neoplasm Staging
Rectal Neoplasms*
Rectum

Figure

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  Fig. 1 Rectal anatomy on magnetic resonance imaging. A. The three layers of the rectum wall (arrows). B. Normal saw-tooth appearance of the anterior longitudinal muscle in the lower rectum (arrows).

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  Fig. 2 The rectal peritoneum.

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  Fig. 3 Anterior peritoneal reflection on magnetic resonance imaging. A. In men, the anterior peritoneal reflecion (arrows) is located just above the tip of the seminal vesicle (asterisk). B. In women, the anterior peritoneal reflecion (arrows) is located at the level of the uterine cervix (asterisk).

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  Fig. 4 Extent of total mesorectal excision.

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  Fig. 5 Anatomy of sphincter complex (arrows).

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  Fig. 6 Magnetic resonance imaging protocol. A. Oblique axial and coronal images are obtained orthogonal (white arrow) or parallel (black arrow) to the long axis of the tumor (asterisk). B. Mucinous lower rectal cancer (asterisk). Oblique axial T2-weighted image with high-resolution and small field-of-view is recommended (an example from our institution: 3 mm slice thickness, 160 mm × 160 mm field-of-view, 256 × 256 pixels, 4–6 excitations, 1.1 mm3 voxel resolution).

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  Fig. 7 Tumor height and morphology. A. Distances from the anal verge and anorectal junction to the distal margin of the tumor (arrows) by a curvilinear measurement (straight line) along the luminal center. B. Polypoid mass with the fibrovascular stalk (arrow) at 11 o'clock position. C. Semi-annular wall thickening with an invasive edge (arrows) at 4–9 o'clock position and two raised rolled edges (asterisks) at 3 and 9 o'clock positions.

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  Fig. 8 T1 rectal cancer (asterisks) with preserved high-signal stripe of the submucosal layer (arrows).

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  Fig. 9 T3 substage. A. Nodular extramural extension. Extramural depth of invasion (arrow) measured by the distance from imaginary line (dashed line) of outer margin for muscularis propria layer to outer margin of tumor. B. Broad-base bulging extramural extension. Extramural depth of invasion (arrow) measured by the distance from imaginary line (red dashed line) of outer margin for muscularis propria layer to outer margin of tumor (white dashed line).

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  Fig. 10 T4a rectal cancer with anterior peritoneal reflection (arrows) invasion.

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  Fig. 11 Compartments of the pelvis. A. Sagittal image shows central compartments above/below the PR (arrow), posterior compartment, and infralevator compartment. B. Oblique axial image shows the lateral compartment. PR = peritoneal reflection.

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  Fig. 12 Lymph node evaluation. A. A 9 mm metastatic mesorectal node with round, irregular margin and internal heterogeneity (arrow). B. A 13 mm metastatic internal iliac node with round and internal heterogeneity (arrow).

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  Fig. 13 Sphincter complex. A. Illustration of magnetic resonance image staging of lower rectal cancer. B. Stage I: lower rectal cancer (arrows) is confined to the bowel wall. C. Stage IV: lower rectal cancer (arrows) invades the intersphincteric plane and left levator ani muscle.

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  Fig. 14 Circumferential resection margin. “Involved” mesorectal fascia at 10–11 o'clock position by direct spreading of the primary tumor (arrow).

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  Fig. 15 Extramural venous invasion. Intermediate tumor signal intensity within the marginated, expanded extramural nodular vein contiguous to the primary tumor (arrow).

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