Abstract
Purpose
To determine if DCE-MRI adds diagnostic value to the combined use of T2WI and DWI-MRI in the determination of clinical complete response (cCR) after neoadjuvant treatment (NAT) in patients with locally advanced rectal cancer.
Methods and materials
In this IRB-approved, HIPAA-compliant retrospective study, response was assessed using a 5-point confidence score by T2WI and DWI-MRI only (‘standard MRI’), then with addition of DCE-MRI. Review of digital rectal exams and endoscopy notes produced a clinical overall response score. The reference standard was CR by histopathology or cCR determined after a minimum of 18 months’ follow-up. Diagnostic accuracy and ROC curves were calculated for standard MRI and added DCE-MRI (to detect complete or good response), for clinical evaluation (to detect CR) and for MRI and clinical methods combined.
Results
Of 65 patients undergoing NAT, 20 had cCR (31%). Sensitivity, specificity and area under the ROC (AUC) were 0.55, 0.87 and 0.69 for clinical evaluation; 0.42, 0.77 and 0.66 for standard MRI, and 0.53, 0.76 and 0.68 for added DCE-MRI, respectively. Combined clinical evaluation and standard MRI with DCE-MRI resulted in the highest specificity of 0.96 and highest AUC of 0.72.
Conclusion
For the assessment of cCR after neoadjuvant therapy using clinical and multi-sequence MRI reading strategies, the addition of DCE-MRI increased specificity and PPV, but not significantly.
Key Points
• The addition of dynamic contrast-enhanced MRI to standard MRI, including DWI-MRI, may not significantly improve accuracy of response assessment in rectal cancer treatment.
• Clinical assessment consisting of digital rectal examination and endoscopy is the most accurate standalone test to assess response to chemoradiotherapy in rectal cancer.
• Combining MRI using DWI and DCE with the clinical assessment may potentially improve the accuracy for response assessment in rectal cancer.
Similar content being viewed by others
Abbreviations
- ADC:
-
Apparent diffusion coefficient
- cCR:
-
Clinical complete response
- cGy:
-
Centigray
- CRT:
-
Chemoradiotherapy
- DCE:
-
Dynamic contrast-enhanced
- ESGAR:
-
European Society of Gastrointestinal and Abdominal Radiologists
- FU:
-
Fluorouracil
- NAT:
-
Neoadjuvant treatment
- NEX:
-
Number of signal averages
- NOM:
-
Non-operative management
- pCR:
-
Pathological complete response
References
Habr-Gama A, Perez RO, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240(4):711–717
Hassan I, Cima RR (2007) Quality of life after rectal resection and multimodality therapy. J Surg Oncol 96:684–692
Maas M, Lambregts DM, Nelemans PJ et al (2015) Assessment of clinical complete response after chemoradiation for rectal cancer with digital rectal examination, endoscopy, and MRI: selection for organ-saving treatment. Ann Surg Oncol 22:3873–3880
Gollub MJ, Gultekin DH, Akin O et al (2012) Dynamic contrast-enhanced MRI for the detection of pathological complete response to neoadjuvant chemotherapy for locally advanced rectal cancer. Eur Radiol 22(4):821–831. 102
Hötker AM, Tarlinton L, Mazaheri Y et al (2016) Multiparametric MRI in the assessment of response of rectal cancer to neoadjuvant chemoradiotherapy: a comparison of morphological, volumetric and functional MRI parameters. Eur Radiol 26:4303–4312
Dijkhoff RAP, Beets-Tan RGH, Lambregts DMJ, Beets GL, Maas M (2017) Value of DCE-MRI for staging and response evaluation in rectal cancer: a systematic review. Eur J Radiol 95:155–168
Smith JJ, Chow OS, Gollub MJ et al (2015) Organ preservation in rectal adenocarcinoma: a phase II randomized controlled trial evaluating 3-year disease-free survival in patients with locally advanced rectal cancer treated with chemoradiation plus induction or consolidation chemotherapy, and total mesorectal excision or nonoperative management. BMC Cancer 15:767–780
Habr-Gama A, Perez RO, Wynn G, Marks J, Kessler H, Gama-Rodrigues J (2010) Complete clinical response after neoadjuvant chemoradiation therapy for distal rectal cancer: characterization of clinical and endoscopic findings for standardization. Dis Colon Rectum 53(12):1692–1698
Guillem JG, Chessin DB, Shia J et al (2005) Clinical examination following preoperative chemoradiation for rectal cancer is not a reliable surrogate end point. J Clin Oncol 23(15):3475–3479
Lambregts DM, Maas M, Bakers FC et al (2011) Long-term follow-up features on rectal MRI during a wait-and-see approach after a clinical complete response in patients with rectal cancer treated with chemoradiotherapy. Dis Colon Rectum 54(12):1521–1528
Curvo-Semedo L, Lambregts DM, Maas M et al (2011) Rectal cancer: assessment of complete response to preoperative combined radiation therapy with chemotherapy--conventional MR volumetry versus diffusion-weighted MR imaging. Radiology 260(3):734–743
Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35
DeLong ER, DeLong DM, Clarke-Pearson DL (1998) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845
van der Paardt MP, Zagers MB, Beets-Tan RG, Stoker J, Bipat S (2013) Patients who undergo preoperative chemoradiotherapy for locally advanced rectal cancer restaged by using diagnostic MR imaging: a systematic review and meta-analysis. Radiology 269(1):101–112
Beets-Tan RGH, Lambregts DMJ, Maas M et al (2017) Magnetic resonance imaging for clinical management of rectal cancer: updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol 28(4):1465–1475
Funding
This study has received funding by NIH.
Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R25CA020449. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Guarantor
The scientific guarantor of this publication is Marc J. Gollub, MD.
Conflict of interest
The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Statistics and biometry
Ms. Andrea Knezevic, MS and Dr. Mithat Gonen, PhD, kindly provided statistical advice for this manuscript.
Informed consent
Written informed consent was waived by the Institutional Review Board.
Ethical approval
Institutional Review Board approval was obtained.
Methodology
• Retrospective
• Diagnostic or prognostic study
• Performed at one institution
Electronic supplementary material
ESM 1
(DOCX 17 kb)
Rights and permissions
About this article
Cite this article
Gollub, M.J., Blazic, I., Felder, S. et al. Value of adding dynamic contrast-enhanced MRI visual assessment to conventional MRI and clinical assessment in the diagnosis of complete tumour response to chemoradiotherapy for rectal cancer. Eur Radiol 29, 1104–1113 (2019). https://doi.org/10.1007/s00330-018-5719-1
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00330-018-5719-1