Skip to main content

Advertisement

SpringerLink
Log in

How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers

  • Hollow Organ GI
  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Purpose

To determine an accurate method for localizing rectal cancer using the distance from the anal verge on preoperative MRI.

Methods

This prospective study included 50 patients scheduled for MRI evaluation of rectal cancer. After rectal filling with gel, MRI was performed with two markers attached at the anal verge. The distance between the tumor and the anal verge on a sagittal T2-weighted image (T2WI) was measured independently by two radiologists using six methods divided into three groups of similar measurement approaches, and compared to those obtained on rigid sigmoidoscopy. The anal verge location relative to the external anal sphincter was assessed on oblique coronal T2WI in reference to the markers. Correlation analysis was performed using the intraclass correlation coefficient (ICC) for verification, and a paired t test was used to evaluate the mean differences.

Results

The highest correlation (ICC 0.797–0.815) and the least mean difference (0.74–0.85 cm) with rigid sigmoidoscopy, and the least standard deviation (3.12–3.17 cm) were obtained in the direct methods group using a straight line from the anal verge to the tumor. The anal verge was localized within a range of − 1.4 to 1.5 cm (mean − 0.31 cm and − 0.22 cm) from the lower end of the external anal sphincter.

Conclusion

The direct methods group provided the most accurate tumor distance among the groups. Among the direct methods, we recommend the direct mass method for its simplicity. Despite minor differences in location, the lower end of the external anal sphincter was a reliable anatomical landmark for the anal verge.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Data availability

Data available on request due to privacy/ethical restrictions.

Abbreviations

T2WI:

T2-weighted image

ICC:

Intraclass correlation coefficient

EAS:

External anal sphincter

References

  1. Tersteeg JJC, Gobardhan PD, Crolla R, Kint PAM, Niers-Stobbe I, Boonman-de Winter LJM, Schreinemakers JMJ (2018) Improving the quality of MRI reports of preoperative patients with rectal cancer: Effect of national guidelines and structured reporting. Am J Roentgenol 210(6):1240-1244. https://doi.org/10.2214/ajr.17.19054

    Article  Google Scholar 

  2. Nougaret S, Reinhold C, Mikhael HW, Rouanet P, Bibeau F, Brown G (2013) The use of MR imaging in treatment planning for patients with rectal carcinoma: have you checked the “DISTANCE”? Radiology 268(2):330-344. https://doi.org/10.1148/radiol.13121361

    Article  PubMed  Google Scholar 

  3. Delli Pizzi A, Basilico R, Cianci R, Seccia B, Timpani M, Tavoletta A, Caposiena D, Faricelli B, Gabrielli D, Caulo M (2018) Rectal cancer MRI: protocols, signs and future perspectives radiologists should consider in everyday clinical practice. Insights inito Imaging 9(4):405-412. https://doi.org/10.1007/s13244-018-0606-5

    Article  Google Scholar 

  4. Beets-Tan RGH, Lambregts DMJ, Maas M, Bipat S, Barbaro B, Curvo-Semedo L, Fenlon HM, Gollub MJ, Gourtsoyianni S, Halligan S, Hoeffel C, Kim SH, Laghi A, Maier A, Rafaelsen SR, Stoker J, Taylor SA, Torkzad MR, Blomqvist L (2018) 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. https://doi.org/10.1007/s00330-017-5026-2

    Article  PubMed  Google Scholar 

  5. Gollub MJ, Arya S, Beets-Tan RG, dePrisco G, Gonen M, Jhaveri K, Kassam Z, Kaur H, Kim D, Knezevic A, Korngold E, Lall C, Lalwani N, Blair Macdonald D, Moreno C, Nougaret S, Pickhardt P, Sheedy S, Harisinghani M (2018) Use of magnetic resonance imaging in rectal cancer patients: Society of Abdominal Radiology (SAR) rectal cancer disease-focused panel (DFP) recommendations 2017. Abdom Radiol (NY) 43(11):2893-2902. https://doi.org/10.1007/s00261-018-1642-9

    Article  Google Scholar 

  6. Cancer KSGfR (2017) Essential Items for Structured Reporting of Rectal Cancer MRI: 2016 Consensus Recommendation from the Korean Society of Abdominal Radiology. Korean J Radiol 18(1):132-151. https://doi.org/10.3348/kjr.2017.18.1.132

    Article  Google Scholar 

  7. Schmoll HJ, Van Cutsem E, Stein A, Valentini V, Glimelius B, Haustermans K, Nordlinger B, van de Velde CJ, Balmana J, Regula J, Nagtegaal ID, Beets-Tan RG, Arnold D, Ciardiello F, Hoff P, Kerr D, Kohne CH, Labianca R, Price T, Scheithauer W, Sobrero A, Tabernero J, Aderka D, Barroso S, Bodoky G, Douillard JY, El Ghazaly H, Gallardo J, Garin A, Glynne-Jones R, Jordan K, Meshcheryakov A, Papamichail D, Pfeiffer P, Souglakos I, Turhal S, Cervantes A (2012) ESMO Consensus Guidelines for management of patients with colon and rectal cancer. a personalized approach to clinical decision making. Ann Oncol 23(10):2479-2516. https://doi.org/10.1093/annonc/mds236

  8. Tanaka A, Sadahiro S, Suzuki T, Okada K, Saito G (2018) Comparisons of rigid proctoscopy, flexible colonoscopy, and digital rectal examination for determining the localization of rectal cancers. Dis Colon Rectum 61(2):202-206. https://doi.org/10.1097/dcr.0000000000000906

    Article  PubMed  Google Scholar 

  9. Chiang JM, Hsieh PS, Chen JS, Tang R, You JF, Yeh CY (2014) Rectal cancer level significantly affects rates and patterns of distant metastases among rectal cancer patients post curative-intent surgery without neoadjuvant therapy. World J Surg Oncol 12:197. https://doi.org/10.1186/1477-7819-12-197

    Article  PubMed  PubMed Central  Google Scholar 

  10. Bhangu A, Rasheed S, Brown G, Tait D, Cunningham D, Tekkis P (2014) Does rectal cancer height influence the oncological outcome? Col Dis 16(10):801-808. https://doi.org/10.1111/codi.12703

    Article  CAS  Google Scholar 

  11. Restivo A, Zorcolo L, Cocco IM, Manunza R, Margiani C, Marongiu L, Casula G (2013) Elevated CEA levels and low distance of the tumor from the anal verge are predictors of incomplete response to chemoradiation in patients with rectal cancer. Ann Surg Oncol 20(3):864-871. https://doi.org/10.1245/s10434-012-2669-8

    Article  PubMed  Google Scholar 

  12. Nielsen LB, Wille-Jorgensen P (2014) National and international guidelines for rectal cancer. Col Dis 16(11):854-865. https://doi.org/10.1111/codi.12678

    Article  CAS  Google Scholar 

  13. Goldenberg BA, Holliday EB, Helewa RM, Singh H (2018) Rectal cancer in 2018: A primer for the gastroenterologist. Am J Gastroenterol 113(12):1763-1771. https://doi.org/10.1038/s41395-018-0180-y

    Article  PubMed  PubMed Central  Google Scholar 

  14. Merchea A, Larson DW (2017) Anus. In: Sabiston DC, Townsend CM (eds) Sabiston textbook of surgery. 20th edn. Elsevier, Philadelphia, pp 1394-1417

    Google Scholar 

  15. Standring S (2016) Large intestine. In: Standring S (ed) Gray’s anatomy, vol Chapter 66. Elsevier, Philadelphia, pp 1136-1159

    Google Scholar 

  16. Floch MH (2020) Anatomy of the colon, rectum, and anus. In: Floch MH, Netter FH (eds) Netter’s gastroenterology. 3rd edn. Elsevier, Philadelphia, pp 280-290

    Google Scholar 

  17. Gorfine SR (2016) Anorectal Crohn’s disease. In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB (eds) The ASCRS textbook of colon and rectal surgery. 3rd edn. Springer, Cham, pp 819-841. https://doi.org/10.1007/978-3-319-25970-3

  18. Han NY, Kim MJ, Park BJ, Sung DJ (2014) Location of rectal cancer as determined using rectal magnetic resonance imaging, and its relationship with pulmonary metastasis. Turk J Gastroenterol 25(6):661-668. https://doi.org/10.5152/tjg.2014.5616

    Article  PubMed  Google Scholar 

  19. Meylemans D, Penninckx F, Vanbeckevoort D, Wolthuis AM, Fieuws S, D’Hoore A (2014) Endoscopic versus radiology-based location of rectal cancer. Acta chirurgica Belgica 114 (6):364-369

    Article  CAS  Google Scholar 

  20. Furey E, Jhaveri KS (2014) Magnetic resonance imaging in rectal cancer. Magn Reson Imaging Clin N Am 22(2):165-190. https://doi.org/10.1016/j.mric.2014.01.004

    Article  PubMed  Google Scholar 

  21. Hoeffel C, Mule S, Laurent V, Bouche O, Volet J, Soyer P (2014) Primary rectal cancer local staging. Diagn Interv Imaging 95(5):485-494. https://doi.org/10.1016/j.diii.2014.03.005

    Article  CAS  PubMed  Google Scholar 

  22. Arya S, Das D, Engineer R, Saklani A (2015) Imaging in rectal cancer with emphasis on local staging with MRI. Indian J Radiol Imaging 25(2):148-161. https://doi.org/10.4103/0971-3026.155865

    Article  PubMed  PubMed Central  Google Scholar 

  23. Garcia Figueiras R, Caro Dominguez P, Garcia Dorrego R, Vazquez Martin A, Gomez Caamano A (2012) Prognostic factors and functional imaging in rectal cancer. Radiologia 54(1):45-58. https://doi.org/10.1016/j.rx.2011.05.017

    Article  CAS  PubMed  Google Scholar 

  24. Paparo F, Puppo C, Montale A, Bacigalupo L, Pascariello A, Clavarezza M, Binda C, Rollandi GA, Binda GA (2014) Comparison between magnetic resonance imaging and rigid rectoscopy in the preoperative identification of intra- and extraperitoneal rectal cancer. Colorectal Dis 16(11):O379-O385. https://doi.org/10.1111/codi.12698

    Article  CAS  PubMed  Google Scholar 

  25. Shihab OC, Moran BJ, Heald RJ, Quirke P, Brown G (2009) MRI staging of low rectal cancer. Eur Radiol 19(3):643-650. https://doi.org/10.1007/s00330-008-1184-6

    Article  PubMed  Google Scholar 

  26. Torkzad MR, Pahlman L, Glimelius B (2010) Magnetic resonance imaging (MRI) in rectal cancer: a comprehensive review. Insights into Imaging 1(4):245-267. https://doi.org/10.1007/s13244-010-0037-4

    Article  PubMed  PubMed Central  Google Scholar 

  27. Donner A, Zou G (2002) Testing the equality of dependent intraclass correlation coefficients. Statistician 51(3):367-379

    Google Scholar 

  28. Walther BA, Moore JL (2005) The concepts of bias, precision and accuracy, and their use in testing the performance of species richness estimators, with a literature review of estimator performance. Ecography 28(6):815-829

    Article  Google Scholar 

  29. Keller DS, Paspulati R, Kjellmo A, Rokseth KM, Bankwitz B, Wibe A, Delaney CP (2014) MRI-defined height of rectal tumours. Br J Surg 101(2):127-132. https://doi.org/10.1002/bjs.9355

    Article  CAS  PubMed  Google Scholar 

  30. Dunaway MT, Webb WR, Rodning CB (1988) Intraluminal measurement of distance in the colorectal region employing rigid and flexible endoscopes. Surg Endosc 2(2):81-83. https://doi.org/10.1007/bf00704359

    Article  CAS  PubMed  Google Scholar 

  31. Schoellhammer HF, Gregorian AC, Sarkisyan GG, Petrie BA (2008) How important is rigid proctosigmoidoscopy in localizing rectal cancer? Am J Surg 196(6):904-908. https://doi.org/10.1016/j.amjsurg.2008.08.005

    Article  PubMed  Google Scholar 

  32. Glimelius B, Tiret E, Cervantes A, Arnold D, ESMO Guidelines Working Group (2013) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 24 Suppl 6:vi81-vi88. https://doi.org/10.1093/annonc/mdt240

Download references

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author information

Authors and Affiliations

  1. Department of Radiology, Korea University Anam Hospital, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea

    Yeo Eun Han, Beom Jin Park, Deuk Jae Sung, Min Ju Kim, Na Yeon Han, Ki Choon Sim & Sung Bum Cho

  2. Department of Surgery, Korea University Anam Hospital, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea

    Jin Kim & Seon-Hahn Kim

  3. Department of Biostatistics, Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea

    Hyonggin An

Authors
  1. Yeo Eun Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Beom Jin Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Deuk Jae Sung
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Min Ju Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Na Yeon Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ki Choon Sim
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sung Bum Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jin Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Seon-Hahn Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hyonggin An
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Beom Jin Park.

Ethics declarations

Conflict of interest

All other authors have no conflicts of interest.

Ethics approval

This study was approved by Institutional Review Board of Korea University Anam Hospital (IRB Number: 2016AN0022).

Informed consent

Written informed consent was obtained from all patients before study enrollment.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Han, Y.E., Park, B.J., Sung, D.J. et al. How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers. Abdom Radiol 46, 449–458 (2021). https://doi.org/10.1007/s00261-020-02654-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-020-02654-9

Keywords

Search

Navigation