Korean J Radiol.  2017 Feb;18(1):132-151. 10.3348/kjr.2017.18.1.132.

Essential Items for Structured Reporting of Rectal Cancer MRI: 2016 Consensus Recommendation from the Korean Society of Abdominal Radiology

• KSAR Study Group for Rectal Cancer

• KMID: 2468128
• DOI: http://doi.org/10.3348/kjr.2017.18.1.132

Abstract

High-resolution rectal MRI plays a crucial role in evaluating rectal cancer by providing multiple prognostic findings and imaging features that guide proper patient management. Quality reporting is critical for accurate effective communication of the information among multiple disciplines, for which a systematic structured approach is beneficial. Existing guides on reporting of rectal MRI are divergent on some issues, largely reflecting the differences in overall management of rectal cancer patients between the United States and Europe. The Korean Society of Abdominal Radiology (KSAR) study group for rectal cancer has developed an expert consensus recommendation regarding essential items for structured reporting of rectal cancer MRI using a modified Delphi method. This recommendation aims at presenting an up-to-date, evidence-based, practical, structured reporting template that can be readily adopted in daily clinical practice. In addition, a thorough explanation of the clinical and scientific rationale underlying the reporting items and their formats is provided. This KSAR recommendation may serve as a useful tool to help achieve more standardized optimal care for rectal cancer patients using rectal MRI.

Keyword

Rectum; Rectal cancer; Staging; Magnetic resonance imaging; Structured; Report; Consensus; Recommendation; Guideline

MeSH Terms

Consensus
*Electronic Health Records
Humans
*Magnetic Resonance Imaging
Neoplasm Staging
Prognosis
Radiography, Abdominal
Rectal Neoplasms/*diagnostic imaging/pathology
Republic of Korea
Societies, Medical

Figure

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  Fig. 1 Longitudinal tumor location. Rectal cancer mass (arrows) is identified by raised rolled-up edges. Anal verge and anorectal junction (dashed lines) are clearly seen on these sagittal planes. Distances from anal verge and anorectal junction to lowest tumor margin, measured on MRI along approximate luminal center of rectum and anus, were 11.5 and 8 cm, respectively. Tumor distance from anal verge measured with flexible sigmoidoscope was 9.5 cm. Mass (arrows) is seen straddling anterior peritoneal reflection, as apex of anterior peritoneal reflection (*) is seen at mid-portion of mass (please see “Tumor Relationship with the Anterior Peritoneal Reflection [Item 3]” section and Figure 2 for further explanations).

• 

  Fig. 2 Anterior peritoneal reflection. A. Schematic shows anterior peritoneal reflection (arrows) and its apex (*), i.e., lowermost point of anterior peritoneal reflection. B. Apex of anterior peritoneal reflection (*) can be identified on sagittal MRI (left) in this male patient by following peritoneal line (arrowheads) over urinary bladder and seminal vesicle and by noting its termination in anterior rectal wall (*). On axial view (right), peritoneal attachment makes “seagull”-like appearance.

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  Fig. 3 Circumferential tumor location. Ulceroinfiltrative cancer mass is observed in rectal wall from 1 o'clock to 8 o'clock position in clockwise direction (arrowheads). Metastatic lymph node abutting left posterolateral side of mesorectal fascia (arrow) is also noted, which predicts tumor involvement of CRM. CRM = circumferential resection margin

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  Fig. 4 T stages. Examples of rectal cancers of various T stages (arrows), including T1 (sagittal and axial), T2 (axial), T3 (axial), T4a (sagittal), and T4b with vaginal invasion (axial).

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  Fig. 5 Measurement of extramural depth of tumor invasion in T3 rectal cancer. A. MRI measurements on axial (left) and coronal (right) views are 6.1 and 6.2 mm, respectively. B. Pathologic measurement using surgical specimen is also 5.5 mm (hematoxylin and eosin stain). All measurements are coherently > 5 mm.

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  Fig. 6 Shortest tumor distance from mesorectal fascia. Direct tumor involvement of right lateral side of mesorectal fascia (arrows), i.e., shortest tumor distance of 0 mm, is noted on axial (left) and coronal (right) views, which predicts tumor involvement of CRM. CRM = circumferential resection margin

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  Fig. 7 Far distal rectal cancer without perirectal extension. Ulcerofungating mass (arrowheads) is noted just above anorectal junction on this coronal image. It is confined within rectal wall and perirectal fat (*) in between lesion and left levator muscle is intact.

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  Fig. 8 Distal rectal cancer with extension to levator ani and anal canal. Large mass with central ulcer is noted in distal rectum on this coronal image. Mass involves both internal and external (white arrowhead) sphincters. Unlike patient's right side, where thin perirectal fatty tissue (open arrows) between far distal rectum and right levator and intersphincteric plane (white arrow) remain intact, tumor has replaced perirectal fat and has extended to levator (open arrowhead) on patient's left side.

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  Fig. 9 Extramesorectal lymph node stations associated with rectal cancer spread. Locations of inguinal nodes (white), external iliac nodes (purple), internal iliac nodes (blue), obturator nodes (pink), and common iliac nodes (yellow) are marked by different colors.

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  Fig. 10 Rectal cancer patient with bilateral internal iliac nodal metastasis (arrows).

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  Fig. 11 Microscopic view of 1-mm lymph node (arrows) that is harboring metastatic foci (arrowheads) (hematoxylin and eosin stain, magnification × 30).

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  Fig. 12 8-mm in short axis, non-metastatic, mesorectal lymph node. Node (arrow) is not considered suspicious if it has regular border and homogeneous signal intensity on MRI (left). Lower rim of lymph node shows low signal intensity due to chemical shift artifact. Microscopic image (right) shows normal lymph node (arrow) (hematoxylin and eosin stain, magnification × 5).

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  Fig. 13 6-mm in short axis, metastatic, mesorectal lymph node. Lymph node (arrow) with irregular border and heterogeneous signal intensity on MRI (left) suggests metastasis. Microscopic image (right) shows metastatic foci (arrowheads) in lymph node (hematoxylin and eosin stain, magnification × 30).

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  Fig. 14 Rectal cancer associated with EMVI A. At initial presentation. EMVI is seen on MRI (coronal image in left and two axial images at slightly different levels in right) as intermediate tumor signal intensity within extramural vessels contiguous to primary tumor (arrows). One involved vessel is markedly expanded with irregular nodular margins. B. After preoperative neoadjuvant chemoradiation therapy, EMVI has markedly decreased (arrows) on MRI (left). Whole mounted surgical specimen (right) shows residual tumor within vessels (arrows) (hematoxylin and eosin stain). EMVI = extramural venous invasion

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