Rectal cancer with complete endoscopic response after neoadjuvant therapy: what is the meaning of a positive MRI?

Abstract

Objectives: To determine the short-term outcomes of discordant tumor assessments between DWI-MRI and endoscopy in patients with treated rectal cancer when tumor-bed diffusion restriction is present ("+DWI").

Methods: In this HIPPA-compliant, IRB-approved retrospective study, rectal MRI and endoscopic reports were reviewed for patients with locally advanced primary rectal adenocarcinoma (LARC) treated with chemoradiotherapy or total neoadjuvant therapy and imaged between January 2016 and December 2019. Eligible patients had a +DWI and endoscopy within 2 weeks of each other. True positive MRI were those with tumor on endoscopy and/or biopsy (TP^a) or in whom endoscopy was negative for tumor, but subsequent 3-month follow-up endoscopy and DWI were both positive (TP^b). The positive predictive value of DWI-MRI was calculated on a per-scan and per-patient basis. DWI-negative MRI exams were not explored in this study.

Results: In total, 397 patients with nonmetastatic primary LARC were analyzed. After exclusions, 90 patients had 98 follow-up rectal MRI studies with +DWI. Seventy-six patients underwent 80 MRI scans and had concordant findings at endoscopy (TPa). Seventeen patients underwent 18 MRI scans and had discordant findings at endoscopy (FP); among these, 4 scans in 4 patients were initially false positive (FP) but follow-up MRI remained +DWI and the endoscopy turned concordantly positive (TP^b). PPV was 0.86 per scan and per patient. In 4/18 (22%) scans and 4/17 (24%) patients with discordances, MRI detected tumor regrowth before endoscopy.

Conclusions: Although most +DWI exams discordant with endoscopy are false positive, 22% will reveal that DWI-MRI detects tumor recurrence before endoscopy.

Key points: • Most often, in post-treatment assessment for rectal cancer when DWI-MRI shows restriction in the tumor bed and endoscopy shows no tumor, +DWI MRI will be proven false positive. • Conversely, our study demonstrated that, allowing for sequential follow-up at a 3-month maximum interval, DWI-MRI may detect tumor presence in the treated tumor bed before endoscopy in 22% of discordant findings between DWI-MRI and endoscopy. • Our results showed that a majority of DWI-MRI-positive scans in treated rectal cancer concur with the presence of tumor on endoscopy performed within 2 weeks.

Keywords: MRI, functional; Rectal cancer; Surgical endoscopy.

Figure 1.

Flowchart of Patient Recruitment

Figure 2.

Example of case with concordant DWI and endoscopy findings (TPa). 67-year-old male post total neoadjuvant treatment A. Axial T2 weighted image of treated tumour bed with scar and residual intermediate signal tumour. B. Axial DWI-MRI, b-800, showing irregular curvilinear and nodular diffusion restriction in rectal wall consistent with incomplete tumour regression C. Flexible sigmoidoscopy of rectum showing circumferential nodular tumour persistence

Figure 3.

Example of case with initially discordant DWI and endoscopy findings (FP) (normal endoscopy not shown) and subsequent concordance for tumour between DWI and endoscopy (TPb). 36-year-old male who underwent total neoadjuvant treatment for mid- and lower rectal adenocarcinoma A. Axial T2 weighted image pre-treatment shows a portion of the tumour B. Axial T2 weighted image after total neoadjuvant treatment shows thick scar in patient’s anterior right quadrant C. Axial DWI-MRI, b1500, showing focal area of restriction (arrow). Some ghosting artefact that is minimal does not interfere with interpretation. Endoscopy (not shown) was normal at this time. D. Axial T2 weighted image 11 weeks later shows thick scar in patient’s anterior right quadrant E. Axial DWI-MRI, b1500, 11 weeks later, showing increase size of same area of focal restriction (arrow). F. Flexible sigmoidoscopy shows small raised tumour nodule (arrow).