Rectal carcinoma is one of the biggest cancers of our time, and catching it early at a treatable stage is crucial to patient management, outcome, and quality of life. As new tools shape practice, discussion is focusing on how much the old challenges of managing this disease can be resolved.

In today’s session, leading experts who have developed MRI for detection and as a guidance tool for patient selection and surgical planning will discuss how and why the modality continues to be pivotal in the management of the disease. Given rectal carcinoma’s status as one of the major cancers impacting imaging departments, and MRI’s as the main diagnostic work-up and treatment planning modality, the session should appeal to a wide range of ECR 2020 attendees.

Baseline MRI scan of a patient with rectal cancer: T2-weighted in sagittal, coronal, and axial planes, diffusion-weighted image, postcontrast T1w FS in coronal and axial planes (provided by Dr. Ivana Blažić).

Presenting the keynote lecture, Prof. Richard (‘Bill’) Heald, the surgeon who established total mesorectal excision (TME) surgery in 1982 in Basingstoke, U.K., will discuss the ongoing role of this ground-breaking approach.

“Using TME combined with preoperative radiotherapy and preoperative MR imaging, treatment could be more precisely delivered and outcome tremendously improved,” noted Prof. Regina Beets-Tan, speaking to ECR Today ahead of the congress.

Over the past decade, work by surgeons such as Dr. Angelita Habr-Gama from São Paulo, Brazil, and Prof. Geerard Beets from Amsterdam kept the field moving forward towards minimally invasive treatment and organ preservation, she noted, pointing to the “excellent and practice changing” long-term outcomes of 1,000 patients internationally treated with ‘Watch & Wait’, which were published in The Lancet a year ago.

“Patients with complete response after preoperative chemoradiotherapy are now offered non-operative management as a safe alternative to standard resection,” she said.

Beets-Tan, who is chair of the radiology department at the Netherlands Cancer Institute in Amsterdam, president of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), and 2nd Vice-President of the ESR, will address the new challenges for MRI and the role of radiologists in the selection and follow-up of rectal carcinoma patients.

“The radiologists’ task will go beyond evaluating and reporting images. They will have to work closely together with clinical partners and be part of a dedicated team,” she noted.

Integrated diagnostics

Rectal carcinoma patients require significant expertise, notably in the field of integrated diagnostics, according to fellow speaker Prof. Lennart Blomqvist, professor of radiology in the department of imaging and physiology at the Karolinska University Hospital and the Karolinska Institute.

PET/MRI, for example, allows for more complex mapping of the disease than has been possible before, which when combined with pathology and biology could have implications for diagnosis, prognosis, and treatment-response monitoring. The challenge is knowing how to use this current research tool most effectively in practice to optimise patient management, he explained.

Blomqvist anticipates questions about the role of functional imaging techniques in rectal cancer, how and when it is important to characterise mesorectal disease, and whether it is possible to select patients for surgery or non-surgical approaches based on MRI results.

One of the major issues in rectal cancer MRI is how far lymph nodes should be characterised, particularly small metastases. Do they need to be found or seen? There are mixed opinions as to whether such visualisation changes prognosis and treatment.

Within the rectal ‘embryological package’ to be surgically removed, such small metastases are less problematic than those outside of the package, he added. The important aspect is to what extent this increases operation time, raises costs, and leads to more complications.

The clinical role of functional MRI, such as diffusion-weighted and perfusion imaging in the field, is another source of debate. Radiologists today can estimate cancer aggressiveness and treatment effect with several other new potential imaging biomarkers.

Rectal carcinoma historically had a bad prognosis, with almost half of patients developing local recurrence post-surgery. In the late 1970s, Heald’s surgical technique of diathermy and detailed anatomical dissection, resulted in only 5% to 10% of patients going on to develop local recurrence. Heald, who is chair of the colorectal cancer programme at the Champalimaud Institute in Lisbon, a professor of surgery at the University of Southampton, and surgical director of the Pelican Cancer Foundation, Basingstoke, U.K., took the technique to Scandinavia in the early 1990s, where he met Blomqvist, then a PhD student writing his thesis on rectal MRI. Together the two developed MRI-guidance for cancer visualisation ahead of fine dissection.

Historic session

Moderator Dr. Ivana Blažić noted that the session will present delegates with the opportunity to hear from the most prominent European researchers involved in rectal cancer management – not only Heald, whose TME procedure is still the gold standard for rectal cancer surgery, but also leading European radiologists in the field.

“Nowadays, many rectal cancer patients are treated initially with chemoradiation therapy and some of them show complete response, so that less invasive procedures can be performed such as transanal excision or nonoperative management. Today, the crucial challenge in the management of patients with rectal cancer is how to select those complete responders with the highest possible accuracy,” noted Blažić, MRI section head at the Zemun Medical Centre in Belgrade.

The session will highlight the importance of organ preservation in patients with complete tumour response and the pivotal role of imaging in selection of those patients. Also, future developments in rectal cancer MRI and the role of PET/MRI in rectal cancer patients will be discussed.

“In many ways it will be a historical rectal cancer session, and we expect high attendance. All radiologists, both specialised in abdominal and gastrointestinal imaging and general radiologists, are invited to come to gain an insight into how pivotal imaging is today for clinical decision making,” she said.

Note: For ECR 2020 in July, Dr. Ivana Blažić was replaced by Dr. Dow-Mu Koh.

LIVE
Special Focus Session, Sunday, July 19, 17:00–18:00
SF 5 MRI of rectal carcinoma

  • Chairperson’s introduction
    Dow-Mu Koh; Sutton/UK
  • Keynote lecture: The disappearing rectal cancer: the radio-surgical challenge of our time
    Richard John Heald; Southampton/UK
  • Rectal cancer revisited: Dutch perspective
    Regina G.H. Beets-Tan; Amsterdam/NL
  • Rectal cancer revisited: UK perspective
    Gina Brown; Sutton/UK
  • Rectal cancer: old challenges, new tools
    Lennart K. Blomqvist; Stockholm/SE
  • Live Q&A: Role of the radiologist in diagnosis and management of rectal cancer 

FURTHER READING

Lambregts DMJ, Maas M, Boellaard TN et al (2019) Long-term imaging characteristics of clinical complete responders during watch-and-wait for rectal cancer-an evaluation of over 1500 MRIs. Eur Radiol. doi: 10.1007/s00330-019-06396-1: european-radiology.org/6396

Santiago I, Barata M, Figueiredo N et al (2019) The split scar sign as an indicator of sustained complete response after neoadjuvant therapy in rectal cancer. Eur Radiol. doi: 10.1007/s00330-019-06348-9: european-radiology.org/6348

Gollub MJ, Blazic I, Felder S et al (2019) 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(3):1104-1113: european-radiology.org/5719

Brown PJ, Rossington H, Taylor J et al (2019) Standardised reports with a template format are superior to free text reports: the case for rectal cancer reporting in clinical practice. Eur Radiol. 29(9):5121-5128: european-radiology.org/6028

Beets-Tan RGH, Lambregts DMJ, Maas M et al (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: european-radiology.org/5026