European Radiology

, Volume 29, Issue 3, pp 1104–1113 | Cite as

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

  • Marc J. GollubEmail author
  • Ivana Blazic
  • Seth Felder
  • Andrea Knezevic
  • Mithat Gonen
  • Julio Garcia-Aguilar
  • P. Phillip Paty
  • J. Joshua Smith



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.


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.


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.


Rectal cancer Chemoradiotherapy Magnetic resonance imaging 



Apparent diffusion coefficient


Clinical complete response






Dynamic contrast-enhanced


European Society of Gastrointestinal and Abdominal Radiologists




Neoadjuvant treatment


Number of signal averages


Non-operative management


Pathological complete response



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.

Compliance with ethical standards


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.


• Retrospective

• Diagnostic or prognostic study

• Performed at one institution

Supplementary material

330_2018_5719_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 17 kb)


  1. 1.
    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):711–717Google Scholar
  2. 2.
    Hassan I, Cima RR (2007) Quality of life after rectal resection and multimodality therapy. J Surg Oncol 96:684–692CrossRefGoogle Scholar
  3. 3.
    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 22:3873–3880CrossRefGoogle Scholar
  4. 4.
    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. 102Google Scholar
  5. 5.
    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 26:4303–4312CrossRefGoogle Scholar
  6. 6.
    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 95:155–168CrossRefGoogle Scholar
  7. 7.
    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 15:767–780CrossRefGoogle Scholar
  8. 8.
    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):1692–1698CrossRefGoogle Scholar
  9. 9.
    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):3475–3479CrossRefGoogle Scholar
  10. 10.
    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):1521–1528CrossRefGoogle Scholar
  11. 11.
    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):734–743CrossRefGoogle Scholar
  12. 12.
    Youden WJ (1950) Index for rating diagnostic tests. Cancer 3:32–35CrossRefGoogle Scholar
  13. 13.
    DeLong ER, DeLong DM, Clarke-Pearson DL (1998) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845CrossRefGoogle Scholar
  14. 14.
    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):101–112CrossRefGoogle Scholar
  15. 15.
    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):1465–1475Google Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Department of RadiologyMemorial Sloan Kettering Cancer CenterNew YorkUSA
  2. 2.Department of RadiologyClinical Hospital Center ZemunBelgradeSerbia
  3. 3.Department of Surgery, Colorectal ServiceMemorial Sloan Kettering Cancer CenterNew YorkUSA
  4. 4.Department of Surgery and Gastrointestinal OncologyMoffitt Cancer CenterTampaUSA
  5. 5.Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkUSA

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