Gastrointestinal Imaging Original Research

Zhang et al. MRI of Rectal Carcinoma Gastrointestinal Imaging Original Research

3-T MRI of Rectal Carcinoma: Preoperative Diagnosis, Staging, and Planning of Sphincter-Sparing Surgery
Xiao Ming Zhang1,2 Hong Lei Zhang2 Dexin Yu1 Yong Dai 3 Dongsong Bi 3 Martin R. Prince2 Chuanfu Li1
Zhang XM, Zhang HL, Yu D, et al.

OBJECTIVE. The purpose of this study was to assess the accuracy of 3-T MRI in the preoperative diagnosis, staging, and planning of surgical management of rectal carcinoma. SuBJECTS and METHOdS. Thirty-eight patients (23 men, 15 women) with clinically suspected rectal carcinoma underwent 3-T MRI. Coronal, axial, and sagittal T2-weighted sequences with and without fat suppression; axial T1-weighted spin-echo sequences; axial T1-weighted gradient-echo sequences with and without fat suppression; oblique 2D MR hydrography; and 3D fat-suppressed dynamic contrast-enhanced MRI were performed. Image quality with these sequences was evaluated by three radiologists experienced in body MRI. The significance of difference in results with the sequences was tested. The manner in which MRI staging and feasibility of sphincter-sparing surgery agreed with operative and pathologic findings was evaluated with kappa statistics. RESuLTS. Rectal carcinoma was identified on MRI and confirmed histologically in all 38 patients. MRI findings were correctly predictive of T category in 35 cases (accuracy, 92.1%). In 31 (96.9%) of 32 resectable cases, sphincter-sparing surgical approaches were accurately chosen on the basis of MRI findings. Among the 11 sequences, 3D fat-suppressed dynamic contrast-enhanced MRI best delineated tumor margins. Coronal and axial T2weighted images also well depicted tumor margins with minimal artifact. T2-weighted images were superior to unenhanced T1-weighted images. COnCLuSIOn. MRI of rectal cancer at 3 T is accurate for prediction of T category and the feasibility of sphincter-sparing surgery. The best images were obtained with coronal, sagittal, and axial T2-weighted sequences and 3D fat-suppressed dynamic contrast-enhanced MRI. olorectal carcinoma is the second most common cancer in Western society with 148,620 new cases and 55,170 deaths in the United States each year [1], and the worldwide incidence is rapidly increasing as diet and lifestyles change. Accurate preoperative diagnosis and staging of rectal carcinoma, which are essential for treatment planning and prognosis, can be achieved with endorectal sonography [25] and CT [6, 7]. Because of its superior soft-tissue contrast and multiplanar capability, MRI is becoming increasingly accepted by radiologists, surgeons, and patients for imaging of the rectum. Use of MRI also eliminates the risks of ionizing radiation and nephrotoxicity from iodinated contrast material. Most studies of rectal MRI have been performed with a field strength of 1.5 T or lower [811] because susceptibility artifacts from bowel gas increase at higher field strength.

Keywords: dynamic contrast enhancement, MRI, rectal carcinoma DOI:10.2214/AJR.07.2505 Received May 3, 2007; accepted after revision November 12, 2007. Supported by the Foundation of Shandong Province, Department of Health (no. 2005JW017), Peoples Republic of China.
1

Department of Radiology, Qilu Hospital of Shandong University, 107 Wenhuaxi Rd., Jinan, Shandong, China 250012. Address correspondence to C. Li (chuanfu.li@ gmail.com).

2 Department of Radiology, Weill Medical College of Cornell University, New York, NY. 3 Department of Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.

AJR 2008; 190:12711278 0361803X/08/19051271 American Roentgen Ray Society

This artifact, however, can be reduced with the use of spin-echo sequences and distention of the rectum with warm water. In a preliminary study, Chun et al. [12] found that 3-T high-field-strength MRI with only four MR sequences and without gadolinium enhancement or MR hydrography was almost as accurate as endorectal sonography for staging rectal carcinoma. Another study [13] of the use of 3-T MRI with a four-channel phased-array coil in the diagnosis of rectal cancer also showed promising results with T2-weighted fast spin-echo sequences in the axial and sagittal planes and 2D T1-weighted sequences with fat saturation before and after gadolinium enhancement. There remains uncertainty, however, about the optimal pulse sequences, and there are limited data on the diagnostic accuracy of rectal MRI at 3 T. The lack of a standard protocol causes inconsistent diagnostic accuracy among institutions. The purpose of this study was to

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Zhang et al. evaluate the image quality of various 3-T MRI sequences for preoperative staging and planning of sphincter-sparing resection of rectal cancer. Subjects and Methods Patients
From January 2005 to February 2006, 38 patients (23 men, 15 women; mean age, 60 years; range, 2185 years) consecutively referred for MRI of the rectum because of clinical suspicion of rectal carcinoma were invited to participate in this research study on preoperative imaging. Clinical manifestations included guaiac-positive stool (n = 34), narrowing of the stool (n = 16), constipation (n = 6), abnormal finding at digital rectal examination (n = 24), and abnormal finding at endoscopy (n = 35). All invited patients agreed and gave written informed consent as authorized by the hospital ethics committee. Before MRI, bowel preparation included laxative cleansing (oral administration of magnesium sulfate at a dose of 20 g/100 mL followed by oral hydration the night before rectal MRI for inpatients or 20-mL glycerin enema 1 hour before rectal MRI for outpatients), luminal distention with warm sodium chloride enema, and 10 mg of anisodamine by intramuscular injection 10 minutes before the examination to reduce bowel peristalsis. Before anisodamine was administered, patients were interviewed to exclude contraindications to use of this agent, such as glaucoma, prostate gland hyperplasia, and cardiac disease. prescribed radially centered on the tumor at the position of any luminal stenosis. Three-dimensional dynamic gadoliniumenhanced MRI was performed with an axial multiphase spoiled gradient-echo sequence with fat suppression. The temporal resolution was 1316 seconds per phase. Dynamic contrast-enhanced MRI acquisition was started simultaneously with IV injection of a standard dose (0.1 mmol/ kg) of gadopentetate dimeglumine (Magnevist, Bayer HealthCare) and repeated continuously for 1520 phases with a total data acquisition time of approximately 4 minutes. The gadolinium contrast agent was injected at a rate of 3 mL/s with a power injector (Spectris MR, Medrad) and followed by a bolus of 20 mL of normal saline solution at the same injection rate. was identified. Metastatic disease outside the field of view of pelvic MRI was not assessed. To predict the feasibility of sphincter-sparing surgery, the distance from the lower margin of a rectal tumor to the point at which the levator ani muscle attached to the rectum was measured. The surgeons preferred this landmark to the dentate line because it was considered easier to identify on MRI, particularly on coronal T2-weighted images, and because it is a more reliable marker of the superior sphincter margin. If the distance was 2 cm or greater, sphincter- and anus-sparing surgery was considered feasible. Surgical plans determined with MRI findings were correlated with the operative findings.

Statistical Method
The significance of differences among sequences was tested with ridit analysis (a statistical method used to describe differences between groups on an ordered categoric basis) and ordinal logistic regression for image quality, artifacts, and depiction of rectal tumor border with normal rectal wall. The kappa statistic was used to evaluate the manner in which MRI staging and judgment about feasibility of sphincter-sparing surgery for rectal cancer agreed with the operative and pathologic findings. A value of p < 0.05 in a two-tailed test was considered statistically significant. All analyses were performed with SAS software (version 9.1, SAS Institute).

Image Analysis
MR images were evaluated independently by three radiologists with more than 8 years of experience in interpreting body MR images. The reviewers were blinded to all clinical information. Images obtained with all sequences were presented to each reviewer simultaneously without control of the order in which the reviewers focused on the MR sequences. In this way the reviewers could directly compare images obtained with the various sequences side by side to assess relative image quality. Overall image quality was graded on a fourpoint scale as follows: 0, nondiagnostic; 1, poor image quality but still diagnostic; 2, good image quality; 3, excellent image quality. Other factors evaluated were artifacts (0, artifact interfering with diagnosis; 1, moderate artifact not interfering with diagnosis; 2, mild artifact; 3, no artifact) and depiction of the border between rectal tumor and normal rectum (0, no distinct border visualized; 1, moderate blurring of rectal wall, rectal tumor border not clearly identified; 2, mild blurring of rectal wall, rectal tumor border identified; 3, welldemarcated tumor border). Each rectal tumor was staged according to MRI features and later correlated with the operative and pathologic findings. T1 and T2 categories were not differentiated in this study. T1 and T2 lesions were differentiated from T3 lesions by identification of a smooth outer tumor border within the rectal wall with no invasion into fat surrounding the rectum. T3 lesions had irregular outer borders and invasion into fat surrounding the rectum with plaque, mass, or cordlike signal intensity projecting into perirectal fat. In T4 lesions, fat planes between rectal carcinoma and surrounding organs disappeared. Lymph nodes 1 cm or larger within the field of view were diagnosed on MRI as lymph node metastasis. Metastasis to other organs within the field of view also

MRI Technique
All patients were examined freely breathing in the supine position on a 3-T MRI unit (Signa Excite, GE Healthcare). The body coil was used for signal transmission, and an eight-channel phasedarray surface coil was used for signal reception. A landmark was made on the pubic symphysis. An initial three-plane localizer view covering the entire pelvis was obtained. Subsequent sequences included coronal, axial, and sagittal T2weighted images; axial T2-weighted images with fat suppression; axial T1-weighted gradient-echo images; axial T1-weighted gradient-echo images with fat suppression; radial oblique 2D MR hydrographic single-shot fast spin-echo images; and axial 3D fat-suppressed dynamic gadoliniumenhanced MR images (Fig. 1). An axial T1weighted spin-echo sequence was added for the last 14 patients. Coronal and sagittal T2-weighted sequences with fat suppression were added if necessary as determined by the supervising radiologists. The imaging parameters for each sequence are listed in Table 1. Two-dimensional MR hydrography was performed with at least five slices

Results All patients tolerated the pre-MRI bowel preparation well; the average volume of sodium chloride enema was 360 mL (range, 200500 mL). All MRI examinations were of diagnostic quality. The average imaging time was 35 minutes (range, 3040 minutes) plus approximately 10 minutes for patient preparation. Rectal carcinoma was identified on MRI in all 38 patients and was confirmed at histologic examination of surgical (n = 32) and biopsy (n = 6) specimens. The mean tumor size was 5.2 cm (range, 2.510 cm). Histologic classification of the tumors showed seven well-differentiated adenocarcinomas (Fig. 2), 14 moderately well-differentiated adenocarcinomas (Fig. 3), 13 poorly differentiated adenocarcinomas, and four signetring cell carcinomas. Histopathologic staging revealed two lesions in category T1, 11 in category T2, 21 in category T3 (Fig. 4), and four in category T4 (Fig. 5). Lymph node metastasis was confirmed in 17 patients. Two patients were found to have distal metastasis (liver, lung), which was identified with separate abdominal MRI and chest CT examinations

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MRI of Rectal Carcinoma

Fig. 175-year-old man with poorly differentiated rectal adenocarcinoma (arrows). Preoperative MRI T category was T2 (smooth outer tumor border within rectal wall and no invasion into fat surrounding rectum), and preoperative 3-T MRI showed tumor had invaded anal sphincter. MRI findings were confirmed at surgery, and patient underwent abdominoperineal resection. A, Coronal T2-weighted fast-recovery fast spin-echo image. B, Sagittal T2-weighted fast-recovery fast spin-echo image. C, Axial T2-weighted fast-recovery fast spin-echo image. D, Axial T2-weighted fat-suppressed fast-recovery fast spin-echo image. E, Axial T1-weighted fast spoiled gradient-recalled echo image. F, Axial T1-weighted fat-suppressed fast spoiled gradient-recalled echo image. G, Axial T1-weighted fast spin-echo image. H, Three-dimensional fat-suppressed fast spoiled gradient-recalled echo dynamic gadolinium-enhanced image. I, Two-dimensional MR hydrographic single-shot fast spin-echo image. J, Photograph shows surgical specimen.

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Zhang et al.
No. of Frequency Signals Field of Acquisition Fat Direction Flip Angle Matrix Size Averaged View (mm) Time Suppression
NoteAll sequences performed with free breathing and eight-channel phased-array surface coil. FSPGR = fast spoiled gradient-recalled echo, FSE = fast spin-echo, FSE XL = fast spin-echo accelerated, R = right, L = left, A = anterior, P = posterior, S = superior, I = inferior, NA = not available. aPerformed with respiratory gating.

380 380

360 360

360 360

360 360

380 380

290 290

290 290

350 350

350 350

350 350

240 240

performed on a later date. Twenty-five patients underwent sphincter-sparing resection of the rectum, and seven underwent abdominoperineal excision. In four patients, the tumor was not completely resected owing to local tumor extent. Instead, diverting colostomy was performed to relieve intestinal obstruction. The two patients with distal metastasis were treated with chemotherapy without undergoing surgery. One of these two patients also underwent radiation therapy. MR Image Quality The mean ridits of image quality scores for each 3-T MRI sequence are shown in Table 2 with a statistically significant difference (p < 0.0001). According to the mean ridit of each sequence, among the 11 sequences, 3D fat-suppressed dynamic gadolinium-enhanced MRI was considered to provide the best delineation of tumor margins. Coronal T2-weighted and axial T2weighted images also depicted tumor margins well and had the highest image quality score with the least artifact. In general, T2weighted images were superior to T1-weighted images (p < 0.0001) in ordinal logistic regression. For T1-weighted images, the fast spin-echo sequence was better than the spoiled gradient-recalled echo sequence (p < 0.05) in ordinal logistic regression, although the acquisition time was longer. The lesions were depicted more clearly on sequences without fat suppression than on those with fat suppression because the high signal intensity of fatty tissue surrounding the rectum gave better contrast to the tumor with lower signal intensity. Radially oblique MR hydrography depicted the rectal lumen similarly to barium enema, showing endoluminal features such as filling defects and ulcerations, but did not show mural features. Diagnosis, Staging, and Planning of Sphincter-Saving Surgery With MRI, T category was correctly estimated for 35 of the 38 patients (accuracy, 92.1%; = 0.86, p < 0.0001) (Table 3). In the evaluation of tumor invasion into fat tissue surrounding the rectum to differentiate T3 or higher from T2 or lower, surgical findings confirmed 25 cases with invasion and 13 without invasion; 35 of 38 cases were depicted accurately with MRI (accuracy, 92.1%; = 0.83; p < 0.0001). MRI showed four of four rectal carcinomas with invasion to adjacent organs, which differentiated category T4 from category T3 with an accuracy of 100%. With MRI, 11

Yes

Yes

Yes

Yes

Yes 1329 s NA 384 384 90 S/I 0 50 4,000/634 Single-shot FSE 2D hydrography 62.5 58

3 min 40 s

3 min 23 s

1 min 54 s

2 min 28 s

2 min 28 s

2 min 28 s

2 min 28 s

320 224

320 224

320 224

320 224

320 224

288 192

90

90

90

90

90

90

60

90

90

A/P

R/L

R/L

R/L

R/L

Bandwidth Thickness Interval No. of (kHz) (mm) (mm) Slices

1.5

0.5

0.5

0.5

0.5

1.5

1.5

1.5

31.25

62.5

62.5

62.5

62.5

62.5

62.5

62.5

62.5

3,0003,500a/102

3,0003,500a/102

3,0003,500a/102

3,0003,500a/102

3,0003,500a/85

3,0003,500a/85

TR/TE (ms)

700/8.9

180/2.1

170/1.3

TaBLE 1: MRI Sequence Parameters

Pulse Sequence

Fast-recovery FSE XL

Fast-recovery FSE XL

Fast-recovery FSE XL

Fast-recovery FSE XL

Fast-recovery FSE XL

Fast-recovery FSE XL Sagittal T2-weighted

FSPGR

FSPGR

FSE XL

Axial T1-weighted

Axial T2-weighted

Coronal T2-weighted

Coronal T2-weighted

Sagittal T2-weighted

Axial T1-weighted

Axial T1-weighted

Axial T2-weighted

Projection

1274

3D gadoliniumenhanced FSE

FSPGR

4.1/1.9

62.5

1020

20

20

17

18

18

18

18

15

11

R/L

S/I

S/I

S/I

S/I

20

256 192

320 192

320 192

320 192

~ 4 min

18 s

16 s

Yes

No

No

No

No

No

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MRI of Rectal Carcinoma of 17 patients with lymph node metastasis and 19 of 21 patients without nodal metastasis were correctly identified (accuracy, 79.0%; = 0.56; p < 0.001) (Table 4). For the 32 resectable tumors, with a 2 cm or greater distance between the lower margin of rectal cancer to the point at which the levator ani muscle attached to the rectum as the criterion for predicting the feasibility of sphincter-sparing surgery, MRI was accurate for determining the surgical approach in 31 cases (accuracy, 96.9%; = 0.9; p < 0.0001). The only patient with less than 2 cm between the tumor and the levator ani muscle had T2 well-differentiated rectal adenocarcinoma. This patient underwent internal sphincter resection with prolapsing technique to save at least the external sphincter and anus, although the distance was only 1.5 cm on MRI. Discussion The anatomic location, fixation in the pelvic fat, and lack of peristalsis make the rectum an ideal organ for imaging with MRI [14]. Although rectal tumors can be diagnosed with digital examination, barium enema, and colonoscopy or sigmoidoscopy, these endoluminal techniques do not provide sufficient information about the extraluminal spread of tumor for preoperative planning. Rectal MRI has the benefits of multiplanar imaging and excellent contrast between tumor and perirectal fat, which helps precisely show the tumor and its extent for surgical planning and staging. Some authors [11] recommend MRI for imaging lowlying rectal cancer because MRI has better
Ridit Depiction of Border Between Rectal Tumor and Normal Rectum 0.58 0.51 0.53 0.51 0.56 0.41 0.20 0.27 0.29 0.61

Fig. 257-year-old man with T1 well-differentiated rectal adenocarcinoma (arrow). Coronal T2-weighted MR image shows distance from lower margin of rectal cancer to upper margin of external sphincter, where levator ani muscle (arrowheads) attached to rectum, was 5 cm (double arrow). Patient underwent sphincter-sparing resection of rectum.

Fig. 358-year-old man with T2 moderately differentiated rectal adenocarcinoma (arrow). Coronal T2-weighted MR image shows distance from lower margin of rectal tumor to point where levator ani muscle (arrowheads) attaches to rectum is 1.5 cm (double arrow). Patient underwent internal sphincter resection with prolapsing technique to save external sphincter and anus.

Fig. 475-year-old man with T3 rectal carcinoma. Axial T2-weighted MR image shows rectal tumor (arrow) and local lymph node metastasis (arrowhead).

Fig. 572-year-old man with T4 rectal adenocarcinoma. Axial T2-weighted MR image shows tumor (arrow) with invasion into prostate gland (arrowhead).

TaBLE 2: Mean Ridit Valuea of Image Quality Scores for Each 3-T MRI Sequence

Sequence Coronal T2-weighted Coronal T2-weighted with fat suppression Sagittal T2-weighted Sagittal T2-weighted with fat suppression Axial T2-weighted Axial T2-weighted with fat suppression Axial T1-weighted SPGR Axial T1-weighted SPGR with fat suppression Axial T1-weighted FSE Hydrographic single-shot FSE Axial 3D T1-weighted dynamic gadolinium enhancement

No. of Patientsb 38 9 38 5 38 38 38 38 14 38 38

Image Quality 0.59 0.59 0.54 0.47 0.59 0.58 0.24 0.47 0.49 0.44 0.53

Artifact 0.56 0.53 0.46 0.44 0.54 0.53 0.28 0.34 0.43 0.43 0.47

NoteDash () indicates not available. SPGR = spoiled gradient-recalled echo, FSE = fast spin echo. a A statistical method used to describe differences between groups on an ordered categoric basis. bNumber of patients in whom sequence was performed.

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Zhang et al. TaBLE 3: accuracy of 3-T MRI in TnM Staging of Rectal Cancer
MRI Category T1 + T2 T3 T4 Total Pathologic Category T1 + T2 13 0 0 13 T3 3 18 0 21 T4 0 0 4 4 Total 16 18 4 38

Note = 0.86, p < 0.0001.

soft-tissue contrast than CT in the delineation of invasion of rectal cancer into perianal muscles, prostate gland, and vagina. MRI also clearly shows the mesorectal fascia, which is the border for total mesorectal excision [11, 15]. Because it depicts the characteristic mucinous lakes, MRI is highly accurate in differentiating mucinous from nonmucinous adenocarcinoma [1618]. MRI also may help in differentiation of early recurrence from postoperative changes and in evaluation of perianal fistulas and sinus tracks [1922]. For young patients and patients undergoing multiple examinations, MRI has the advantage of eliminating the risks of ionizing radiation and contrast nephrotoxicity. Various MRI sequences have been used to image the rectum. The image-quality data in this study confirmed that for 3-T units, images obtained with T2-weighted spin-echo sequences are superior to those obtained with T1-weighted sequences, as has been shown for 1.5-T MRI [23]. On T2-weighted images, tumors were slightly better evaluated without fat suppression because on T2weighted images perirectal fat with its high signal intensity has excellent contrast to the tumor. In some cases, however, high-signalintensity perirectal inflammation was better visualized on T2-weighted images with fat suppression. For the two T1-weighted sequences studied, image quality was better with axial T1-weighted fast spin-echo se-

quences, albeit with a longer acquisition time than for the axial T1-weighted gradient-echo sequence, but was still substantially inferior to that of the T2-weighted images. Coronal and sagittal images were especially useful for showing the relations among the tumor, levator ani muscle, and sphincter. All three reviewers identified dynamic contrast-enhanced MRI as the best sequence for depicting tumor margins even through respiratory motion artifact was present. All reviewers considered this sequence essential in the rectal MRI protocol. This finding was consistent with those of a study by Wallengren et al. [24]. In the detection of rectal cancer, those investigators reported 100% sensitivity and 70% specificity of MRI performed with contrast enhancement by superparamagnetic ferristene enema. This double-contrast method also was clinically valuable for staging and determining the depth of tumor invasion into the rectal wall, which was not possible in this study because of our goal of assessing MR hydrography performed with saline enema. MR hydrography has been used successfully to visualize the lumens of biliary ducts, pancreatic ducts, the ureters, and the bladder through depiction of static fluid. In this study, sodium chloride was introduced into the rectum to show the rectal lumen distended with water in a manner similar to that used for 2D single-shot fast spin-echo MR hydrography performed radially to view the endoluminal features from different angles. Depiction of the rectal lumen was similar to that on images from barium enemas. Bowel preparation is crucial to avoid interference from feces and to reduce susceptibility artifact from airtissue borders. In this study, a simplified 20-mL glycerin enema 1 hour before the examination was adequate for patients with rectal cancer in the middle and lower sections who had not yet undergone magnesium sulfate bowel cleansing for surgery. Distention of the rectum is useful but

often is not possible owing to encasement by tumor; at least one group of authors [25] has suggested that bowel preparation and distention are unnecessary. Lauenstein et al. [26] suggested oral administration of multiple doses of gadolinium or barium sulfate beginning 3 days before MRI examination to label feces, entirely avoiding enemas. Many contrast materials have been used to distend the rectum, including air [27], water [28], dilute gadolinium, and other paramagnetic agents [24, 29]. In our study, warm sodium chloride was used mainly because of its low cost, absence of toxicity, and acceptance by patients. In addition to facilitating the diagnosis and staging of rectal tumors, MRI contributes to surgical planning by showing the relations among the tumor, the sphincter, and the levator ani muscle. Sphincter invasion is identified with an accuracy of 87% [30, 31]. Complete tumor resection and sphincter sparing are important goals of rectal surgery to improve quality of life and have fewer complications than abdominoperineal excision. A rectal cancer distal resection margin greater than 2 cm is considered optimal for avoiding recurrence [32]. Thus the length of normal rectum above the levator ani muscle is the key to determining whether sphincter-sparing surgery can be performed. In this study, the distance from the lower margin of rectal cancer to the upper margin of the external sphincter (the point at which the levator ani muscle attaches to the rectum) was measured on good-quality coronal and sagittal images to assess the feasibility of sphincter-sparing surgery with adequate tumor margins. Data on 32 patients with surgical confirmation showed that findings on 3-T MRI were accurate predictors of the feasibility of sphincter-sparing surgery in 31 (96.9%) of the patients. In one patient with a 1.5-cm distance between the tumor and the levator ani muscle, MRI helped the surgeons to plan a modified procedure that spared the external sphincter and anus.

TaBLE 4: accuracy of 3-T MRI Compared with Surgical and Pathologic Findings
Negative Positive TrueTrueFalseFalse- Accuracy Sensitivity Specificity Predictive Predictive Value Positive Negative Positive Negative (%) (%) (%) Value (%) (%) 92.1 22 4 11 25 13 34 19 6 0 0 2 0 3 0 6 1 92.1 100 79.0 96.9 88 100 64.7 96.2 100 100 90.5 100 81.3 100 76 85.7 100 100 84.6 100 0.83 1.00 0.56 0.90 < 0.0001 < 0.0001 < 0.001 < 0.0001 MRI Finding (n)

Finding T category Invasion to fat surrounding rectum Invasion to adjacent organs Lymph node metastasis Sphincter sparing possible

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MRI of Rectal Carcinoma The data on the diagnostic performance of 3-T MRI compare favorably with data on sonography, which is reported to have 69 97% accuracy, and on CT, which has a reported accuracy of 5287% for TNM T categorization of rectal cancer [46, 33, 34]. Endoluminal sonography is reliable in assessing depth of penetration by tumor into the rectal wall, but this technique is invasive and operator dependent. Endoluminal sonography cannot be used to assess tumor close to the sigmoid colon or tumor extension into adjacent organs. CT cannot be used to assess depth of invasion into the rectal wall, but it has the benefits of being fast, having a large field of view, and enabling simultaneous evaluation for distant metastasis. As in other cancers, detecting lymph node metastasis is the most challenging aspect of MRI diagnosis of rectal cancer. Kim et al. [34] found that the accuracy rates of MRI, CT, and endoluminal sonography for local lymph node metastasis of rectal cancer were 63%, 56.5%, and 63.5%, respectively. The accuracy of imaging is low mainly because the diagnosis of metastasis is made only on the basis of the size and shape of lymph nodes, and thus micrometastasis is missed. Because lymph nodes enlarge in both inflammatory and neoplastic processes, which are difficult to differentiate morphologically, false-positive and false-negative results occur. In numerous studies, lymph nodes larger than 1 cm have been considered metastasis [35]; in other studies, cutoffs of 8 mm [36] and 6 mm [37] have been used. With greater than 6 mm as the criterion for the diagnosis of lymph node metastasis around rectal wall and surrounding fat, the sensitivity, specificity, and accuracy were only 57%, 88%, and 76%, respectively [37]. Brown et al. [38] analyzed 437 lymph nodes and concluded that benign and malignant lymph nodes were similar in size. Those authors believed that accuracy could be increased by evaluating lymph node borders and signal intensity. They proposed that using irregular border and mixed signal intensity as the criteria for metastatic lymph nodes would improve sensitivity to 8595% and specificity to 9597%. Heterogeneous contrast enhancement is another indicator of lymph node metastasis [39]. New contrast agents have been developed for detection of metastatic lymph nodes [40, 41], but they were not used in this study. There were additional limitations to this study. With the small number of patients, there were only two T1 lesions, and insufficient number for assessment of the utility of 3-T MRI in differentiating T1 and T2 disease. Therefore, T1 and T2 lesions were combined as T1 and T2 for statistical analyses. Imaging with an endorectal coil to depict the layers of the rectal wall and differentiate T1 from T2 lesions has a reported accuracy of 92% [42, 43]. However, the technique has a limited field of view and requires expertise for coil insertion to avoid rectal injury. The failure rate can be as high as 40% [44]. Endorectal coils can produce artifacts and are of limited use in imaging of tumors close to the sigmoid colon or of obstructing lesions. Phased-array surface coils are more acceptable because of their simplicity and larger, more homogeneous field of view [15, 33], but tumor invasion into the submucosa and muscularis propria of the rectal wall has not been well evaluated. Despite the larger field of view of the eightchannel phased-array coil compared with endorectal coils, this study was limited to the pelvis. Separate examinations of the abdomen and chest were performed to assess the presence of hepatic and pulmonary metastasis. Newer body-array coils and use of total image matrix technique for greater anatomic coverage may make it possible to cover the abdomen and pelvis in a single examination. To save time, three of the sequencesaxial T1-weighted spin echo and coronal and sagittal T2-weighted with fat suppression were not performed for all of the patients. This omission caused bias in comparison of image-quality scores. The added value of 3 T compared with 1.5 T was not directly assessed because the patients underwent only 3-T imaging. It is our impression, however, that the signal-to-noise ratio at 3 T is noticeably greater than that at 1.5 T. We conclude that MRI of rectal cancer at 3 T is accurate for prediction of tumor stage and the feasibility of sphincter-sparing surgery. In clinical practice, a basic imaging protocol can be simplified to four sequences: coronal, sagittal, and axial T2-weighted sequences and 3D fat-suppressed dynamic gadoliniumenhanced MRI. MR hydrographic images and axial T1-weighted fast spin-echo and axial T2-weighted images with fat suppression add only slightly more information. References
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