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Diffusion-weighted MRI to assess response to chemoradiotherapy in rectal cancer: main interpretation pitfalls and their use for teaching

  • Gastrointestinal
  • Published:
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Abstract

Objectives

To establish the most common image interpretation pitfalls for non-expert readers using diffusion-weighted imaging (DWI) to assess response to chemoradiotherapy in patients with rectal cancer and to explore the use of these pitfalls in an expert teaching setting.

Methods

Two independent non-expert readers (R1 and R2) scored the restaging DW MRI scans (b1,000 DWI, in conjunction with ADC maps and T2-W MRI scans for anatomical reference) in 100 patients for the likelihood of a complete response versus residual tumour using a five-point confidence score. The readers received expert feedback and the final response outcome for each case. The supervising expert documented any potential interpretation errors/pitfalls discussed for each case to identify the most common pitfalls.

Results

The most common pitfalls were the interpretation of low signal on the ADC map, small susceptibility artefacts, T2 shine-through effects, suboptimal sequence angulation and collapsed rectal wall. Diagnostic performance (area under the ROC curve) was 0.78 (R1) and 0.77 (R2) in the first 50 patients and 0.85 (R1) and 0.85 (R2) in the final 50 patients.

Conclusions

Five main image interpretation pitfalls were identified and used for teaching and feedback. Both readers achieved a good diagnostic performance with an AUC of 0.85.

Key Points

• Fibrosis appears hypointense on an ADC map and should not be mistaken for tumour.

• Susceptibility artefacts on rectal DWI are an important potential pitfall.

• T2 shine-through on rectal DWI is an important potential pitfall.

• These pitfalls are useful to teach non-experts how to interpret rectal DWI.

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Author information

Authors and Affiliations

  1. Department of Radiology, The Netherlands Cancer Institute, PO Box 90203, 1006 BE, Amsterdam, The Netherlands

    Doenja M. J. Lambregts, Miriam M. van Heeswijk, Max J. Lahaye, Monique Maas & Regina G. H. Beets-Tan

  2. Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands

    Miriam M. van Heeswijk & Frans C. H. Bakers

  3. Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands

    Miriam M. van Heeswijk

  4. GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands

    Miriam M. van Heeswijk, Geerard L. Beets & Regina G. H. Beets-Tan

  5. Department of Neuroscience and Imaging, Gabriele d’Annunzio University, SS. Annunziate Hospital, Chieti, Italy

    Andrea Delli Pizzi

  6. Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands

    Saskia G. C. van Elderen

  7. Department of Radiology, Hospitais Da Universidade De Coimbra, Coimbra, Portugal

    Luisa Andrade

  8. Zuyderland Medical Center, location Heerlen, Heerlen, The Netherlands

    Nicky H. G. M. Peters & Margreet Osinga-de Jong

  9. Department of Radiology, Amphia Hospital, Breda, The Netherlands

    Peter A. M. Kint

  10. Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands

    Shandra Bipat

  11. Department of Radiology, Maxima Medical Centre, Eindhoven-Veldhoven, The Netherlands

    Rik Ooms

  12. Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands

    Geerard L. Beets

Authors
  1. Doenja M. J. Lambregts
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  2. Miriam M. van Heeswijk
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  3. Andrea Delli Pizzi
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  4. Saskia G. C. van Elderen
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  5. Luisa Andrade
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  6. Nicky H. G. M. Peters
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  7. Peter A. M. Kint
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  8. Margreet Osinga-de Jong
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  9. Shandra Bipat
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  10. Rik Ooms
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  11. Max J. Lahaye
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  12. Monique Maas
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  13. Geerard L. Beets
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  14. Frans C. H. Bakers
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  15. Regina G. H. Beets-Tan
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Corresponding author

Correspondence to Doenja M. J. Lambregts.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Doenja Lambregts.

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.

Funding

The authors state that this work did not receive any funding.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Ethical approval

Institutional Review Board approval was obtained.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Overlap of study subjects or cohorts

Some of the study patients were included in previously reported studies, as follows:

Clinical studies

  • The following study included the 38 patients with a clinical complete response after CRT with follow-up according to a watchful waiting strategy:

    • Martens MH, et al. Long-term outcome of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst. 2016;108(12).

    • This study reports the clinical outcomes in these patients and did not focus on imaging.

Studies on diffusion-weighted imaging

  • The following study included one of the patients in our study:

    • Curvo-Semedo L, et al. Rectal cancer: assessment of complete response to preoperative combined radiation therapy with chemotherapy – conventional MR volumetry versus diffusion-weighted MR imaging. Radiology. 2011;260(3):734–43.

    • This study focused on quantitative (ADC and volume) measurements and not on visual assessment of DWI.

  • The following study included 15 of the patients in our study:

    • Lambregts DM, et al. MRI and diffusion-weighted MRI volumetry for identification of complete tunour responders after preoperative chemoradiotherapy in patients with rectal cancer: a bi-institutional validation study. Ann Surg. 2015;262(6):1034–9.

    • This study focused on quantitative (volume) measurements on DWI. It did not include visual DWI assessment, pitfalls or teaching effects.

  • The following study included 12 of the patients in our study:

    • van Heeswijk MM, et al. Automated and semiautomated segmentation of rectal tunour volumes on diffusion-weighted MRI: can it replace manual volumetry? Int J Radiat Oncol Biol Phys. 2016;94(4):824–31.

    • This study was a technical study on automated software methods to measure tumour volumes on DWI. It did not include a visual assessment or comparison of DWI findings with treatment response.

  • The following study included 21 of the patients in our study:

    • van Heeswijk MM, et al. DWI for assessment of rectal cancer nodes after chemoradiotherapy: is the absence of nodes on DWI proof of a negative nodal status? AJR Am J Roentgenol. 2017;208(3):W79–W84.

    • This study focused on DWI for lymph node assessment and not for tumour response evaluation.

Methodology

• Retrospective

• Diagnostic or prognostic study

• Performed at one institution

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Lambregts, D.M.J., van Heeswijk, M.M., Delli Pizzi, A. et al. Diffusion-weighted MRI to assess response to chemoradiotherapy in rectal cancer: main interpretation pitfalls and their use for teaching. Eur Radiol 27, 4445–4454 (2017). https://doi.org/10.1007/s00330-017-4830-z

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  • DOI: https://doi.org/10.1007/s00330-017-4830-z

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