An International Expert-Based Consensus on the Definition of a Clinical Near-Complete Response After Neoadjuvant (Chemo)radiotherapy for Rectal Cancer.

BACKGROUND: A variety of definitions for a clinical near-complete response after neoadjuvant (chemo) radiotherapy for rectal cancer are currently used. This variety leads to inconsistency in clinical practice, long-term outcome, and trial enrollment. OBJECTIVE: The aim of this study was to reach expert-based consensus on the definition of a clinical near-complete response after (chemo) radiotherapy. DESIGN: A modified Delphi process, including a systematic review, 3 surveys, and 2 meetings, was performed with an international expert panel consisting of 7 surgeons and 4 radiologists. The surveys consisted of individual features, statements, and feature combinations (endoscopy, T2-weighted MRI, and diffusion-weighted MRI). SETTING: The modified Delphi process was performed in an online setting; all 3 surveys were completed online by the expert panel, and both meetings were hosted online. MAIN OUTCOME MEASURES: The main outcome was to reach consensus (80% or more agreement). RESULTS: The expert panel reached consensus on a 3-tier categorization of the near-complete response category based on the likelihood of the response to evolve into a clinical complete response after a longer waiting interval. The panelists agreed that a near-complete response is a temporary entity only to be used in the first 6 months after (chemo)radiotherapy. Furthermore, consensus was reached that the lymph node status should be considered when deciding on a near-complete response and that biopsies are not always needed when a near-complete response is found. No consensus was reached on whether primary staging characteristics have to be taken into account when deciding on a near-complete response. LIMITATIONS: This 3-tier subcategorization is expert-based; therefore, there is no supporting evidence for this subcategorization. Also, it is unclear whether this subcategorization can be generalized into clinical practice. CONCLUSIONS: Consensus was reached on the use of a 3-tier categorization of a near-complete response, which can be helpful in daily practice as guidance for treatment and to inform patients with a near-complete response on the likelihood of successful organ preservation. See Video Abstract. UN CONSENSO INTERNACIONAL BASADO EN EXPERTOS ACERCA DE LA DEFINICIN DE UNA RESPUESTA CLNICA CASI COMPLETA DESPUS DE QUIMIORADIOTERAPIA NEOADYUVANTE CONTRA EL CNCER DE RECTO: ANTECEDENTES:Actualmente, se utilizan una variedad de definiciones para una respuesta clínica casi completa después de quimioradioterapia neoadyuvante contra el cáncer de recto. Esta variedad resulta en inconsistencia en la práctica clínica, los resultados a largo plazo y la inscripción en ensayos.OBJETIVO:El objetivo de este estudio fue llegar a un consenso de expertos sobre la definición de una respuesta clínica casi completa después de quimioradioterapia.DISEÑO:Se realizó un proceso Delphi modificado que incluyó una revisión sistemática, 3 encuestas y 2 reuniones con un panel internacional de expertos compuesto por siete cirujanos y 4 radiólogos. Las encuestas consistieron en características individuales, declaraciones y combinaciones de características (endoscopía, T2W-MRI y DWI).AJUSTE:El proceso Delphi modificado se realizó en un entorno en línea; el panel de expertos completó las tres encuestas en línea y ambas reuniones se realizaron en línea.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue llegar a un consenso (≥80% de acuerdo).RESULTADOS:El panel de expertos llegó a un consenso sobre una categorización de tres niveles de la categoría de respuesta casi completa basada en la probabilidad de que la respuesta evolucione hacia una respuesta clínica completa después de un intervalo de espera más largo. Los panelistas coincidieron en que una respuesta casi completa es una entidad temporal que sólo debe utilizarse en los primeros 6 meses después de la quimioradioterapia. Además, se llegó a un consenso en que se debe considerar el estado de los nódulos linfáticos al decidir sobre una respuesta casi completa y que no siempre se necesitan biopsias cuando se encuentra una respuesta casi completa. No se llegó a un consenso sobre si se deben tener en cuenta las características primarias de estadificación al decidir una respuesta casi completa.LIMITACIONES:Esta subcategorización de 3 niveles está basada en expertos; por lo tanto, no hay evidencia que respalde esta subcategorización. Además, no está claro si esta subcategorización puede generalizarse a la práctica clínica.CONCLUSIONES:Se alcanzó consenso sobre el uso de una categorización de 3 niveles de una respuesta casi completa que puede ser útil en la práctica diaria como guía para el tratamiento y para informar a los pacientes con una respuesta casi completa sobre la probabilidad de una preservación exitosa del órgano. (Traducción - Dr. Aurian Garcia Gonzalez).

Imaging in the era of risk-adapted treatment in Colon cancer.

The treatment landscape for patients with colon cancer is continuously evolving. Risk-adapted treatment strategies, including neoadjuvant chemotherapy and immunotherapy, are slowly finding their way into clinical practice and guidelines. Radiologists are pivotal in guiding clinicians toward the most optimal treatment for each colon cancer patient. This review provides an overview of recent and upcoming advances in the diagnostic management of colon cancer and the radiologist's role in the multidisciplinary approach to treating colon cancer.

Impact of the new rectal cancer definition on multimodality treatment and interhospital variability: Results from a nationwide cross-sectional study.

AIM: This study aimed to determine the consequences of the new definition of rectal cancer for decision-making in multidisciplinary team meetings (MDT). The new definition of rectal cancer, the lower border of the tumour is located below the sigmoid take-off (STO), was implemented in the Dutch guideline in 2019 after an international Delphi consensus meeting to reduce interhospital variations. METHOD: All patients with rectal cancer according to the local MDT, who underwent resection in 2016 in the Netherlands were eligible for this nationwide collaborative cross-sectional study. MRI-images were rereviewed, and the tumours were classified as above or on/below the STO. RESULTS: This study registered 3107 of the eligible 3178 patients (98%), of which 2784 patients had an evaluable MRI. In 314 patients, the tumour was located above the STO (11%), with interhospital variation between 0% and 36%. Based on TN-stage, 175 reclassified patients with colon cancer (6%) would have received different treatment (e.g., omitting neoadjuvant radiotherapy, candidate for adjuvant chemotherapy). Tumour location above the STO was independently associated with lower risk of 4-year locoregional recurrence (HR 0.529; p = 0.030) and higher 4-year overall survival (HR 0.732; p = 0.037) compared to location under the STO. CONCLUSION: By using the STO, 11% of the prior MDT-based diagnosis of rectal cancer were redefined as sigmoid cancer, with potential implications for multimodality treatment and prognostic value. Given the substantial interhospital variation in proportion of redefined cancers, the use of the STO will contribute to standardisation and comparability of outcomes in both daily practice and trial settings.

Multi-sequence MRI radiomics of colorectal liver metastases: Which features are reproducible across readers?

PURPOSE: To assess the inter-reader reproducibility of radiomics features on multiple MRI sequences after segmentations of colorectal liver metastases (CRLM). METHOD: 30 CRLM (in 23 patients) were manually delineated by three readers on MRI before the start of chemotherapy on the contrast enhanced T1-weighted images (CE-T1W) in the portal venous phase, T2-weighted images (T2W) and b800 diffusion weighted images (DWI). DWI delineations were copied to the ADC-maps. 107 radiomics features were extracted per sequence. The intraclass correlation coefficient (ICC) was calculated per feature. Features were considered reproducible if ICC > 0.9. RESULTS: 90% of CE-T1W features were reproducible with a median ICC of 0.98 (range 0.76-1.00). 81% of DWI features were robust with median ICC = 0.97 (range 0.38-1.00). The T2W features had a median ICC of 0.96 (range 0.55-0.99) and were reproducible in 80%. ADC showed the lowest number of reproducible features with 58% and median ICC = 0.91 (range 0.38-0.99) When considering the lower bound of the ICC 95% confidence intervals, 58%, 66%, 54% and 29% reached 0.9 for the CE-T1W, DWI, T2W and ADC features, respectively. The feature class with the best reproducibility differed per sequence. CONCLUSIONS: The majority of MRI radiomics features from CE-T1W, T2W, DWI and ADC in colorectal liver metastases were robust for segmentation variability between readers. The CE-T1W yielded slightly better reproducibility results compared to DWI and T2W. The ADC features seem more susceptible to reader differences compared to the other three sequences.

An automated deep learning pipeline for EMVI classification and response prediction of rectal cancer using baseline MRI: a multi-centre study.

The classification of extramural vascular invasion status using baseline magnetic resonance imaging in rectal cancer has gained significant attention as it is an important prognostic marker. Also, the accurate prediction of patients achieving complete response with primary staging MRI assists clinicians in determining subsequent treatment plans. Most studies utilised radiomics-based methods, requiring manually annotated segmentation and handcrafted features, which tend to generalise poorly. We retrospectively collected 509 patients from 9 centres, and proposed a fully automated pipeline for EMVI status classification and CR prediction with diffusion weighted imaging and T2-weighted imaging. We applied nnUNet, a self-configuring deep learning model, for tumour segmentation and employed learned multiple-level image features to train classification models, named MLNet. This ensures a more comprehensive representation of the tumour features, in terms of both fine-grained detail and global context. On external validation, MLNet, yielding similar AUCs as internal validation, outperformed 3D ResNet10, a deep neural network with ten layers designed for analysing spatiotemporal data, in both CR and EMVI tasks. For CR prediction, MLNet showed better results than the current state-of-the-art model using imaging and clinical features in the same external cohort. Our study demonstrated that incorporating multi-level image representations learned by a deep learning based tumour segmentation model on primary MRI improves the results of EMVI classification and CR prediction with good generalisation to external data. We observed variations in the contributions of individual feature maps to different classification tasks. This pipeline has the potential to be applied in clinical settings, particularly for EMVI classification.

Outcomes and potential impact of a virtual hands-on training program on MRI staging confidence and performance in rectal cancer.

OBJECTIVES: To explore the potential impact of a dedicated virtual training course on MRI staging confidence and performance in rectal cancer. METHODS: Forty-two radiologists completed a stepwise virtual training course on rectal cancer MRI staging composed of a pre-course (baseline) test with 7 test cases (5 staging, 2 restaging), a 1-day online workshop, 1 month of individual case readings (n = 70 cases with online feedback), a live online feedback session supervised by two expert faculty members, and a post-course test. The ESGAR structured reporting templates for (re)staging were used throughout the course. Results of the pre-course and post-course test were compared in terms of group interobserver agreement (Krippendorf's alpha), staging confidence (perceived staging difficulty), and diagnostic accuracy (using an expert reference standard). RESULTS: Though results were largely not statistically significant, the majority of staging variables showed a mild increase in diagnostic accuracy after the course, ranging between + 2% and + 17%. A similar trend was observed for IOA which improved for nearly all variables when comparing the pre- and post-course. There was a significant decrease in the perceived difficulty level (p = 0.03), indicating an improved diagnostic confidence after completion of the course. CONCLUSIONS: Though exploratory in nature, our study results suggest that use of a dedicated virtual training course and web platform has potential to enhance staging performance, confidence, and interobserver agreement to assess rectal cancer on MRI virtual training and could thus be a good alternative (or addition) to in-person training. CLINICAL RELEVANCE STATEMENT: Rectal cancer MRI reporting quality is highly dependent on radiologists' expertise, stressing the need for dedicated training/teaching. This study shows promising results for a virtual web-based training program, which could be a good alternative (or addition) to in-person training. KEY POINTS: • Rectal cancer MRI reporting quality is highly dependent on radiologists' expertise, stressing the need for dedicated training and teaching. • Using a dedicated virtual training course and web-based platform, encouraging first results were achieved to improve staging accuracy, diagnostic confidence, and interobserver agreement. • These exploratory results suggest that virtual training could thus be a good alternative (or addition) to in-person training.

Whole-body MRI with diffusion-weighted imaging as an adjunct to18 F-fluorodeoxyglucose positron emission tomography and CT in patients with suspected recurrent colorectal cancer.

AIM: The aim was to explore how findings of whole-body MRI including diffusion-weighted imaging (DW-MRI) compared to the routine diagnostic workup with CT and/or 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT in patients with suspected recurrent colorectal cancer (CRC). METHOD: This was an exploratory retrospective analysis of 55 patients with a clinical suspicion of recurrent CRC who underwent DW-MRI following CT and/or FDG-PET/CT. Two readers in consensus interpreted all clinical imaging reports and converted each described lesion into a confidence score (1 = definitely benign to 5 = definitely malignant). DW-MRI findings were compared to the most recent previous CT or PET/CT. Any discrepant or additional DW-MRI findings were documented and compared with histology and/or clinical follow-up (if available). RESULTS: Whole-body MRI including diffusion-weighted imaging (DW-MRI) resulted in discrepant/additional findings in 26/55 (47%) cases; 23/37 (62%) compared to previous CT and 3/18 (17%) compared to previous PET/CT. These included 10 cases where DW-MRI converted previously inconclusive CT (n = 8) or PET/CT (n = 2) findings into a conclusive diagnosis, one where it contradicted a previous CT diagnosis of recurrence, five where DW-MRI diagnosed recurrent disease not previously reported on CT and 10 cases where DW-MRI detected additional lesions compared to CT (n = 9) or PET/CT (n = 1). Eighty-eight per cent of cases with discrepant/additional findings concerned patients with recurrent/metachronous peritoneal metastases. In total, DW-MRI resulted in 42 discrepant/additional lesions; the DW-MRI diagnosis was correct in 76% of these lesions and incorrect (false positive) in 7%. In the remaining 17%, no standard of reference was available. CONCLUSIONS: This explorative study suggests that DW-MRI may be of added value to patients with a clinical suspicion for recurrent CRC, in particular to identify patients with peritoneal metastases. DW-MRI mainly has potential as a 'problem-solver' in patients with inconclusive or negative findings on previous imaging (in particular CT) and to detect additional disease sites in patients already diagnosed with recurrent disease.

Independent validation of CT radiomics models in colorectal liver metastases: predicting local tumour progression after ablation.

OBJECTIVES: Independent internal and external validation of three previously published CT-based radiomics models to predict local tumor progression (LTP) after thermal ablation of colorectal liver metastases (CRLM). MATERIALS AND METHODS: Patients with CRLM treated with thermal ablation were collected from two institutions to collect a new independent internal and external validation cohort. Ablation zones (AZ) were delineated on portal venous phase CT 2-8 weeks post-ablation. Radiomics features were extracted from the AZ and a 10 mm peri-ablational rim (PAR) of liver parenchyma around the AZ. Three previously published prediction models (clinical, radiomics, combined) were tested without retraining. LTP was defined as new tumor foci appearing next to the AZ up to 24 months post-ablation. RESULTS: The internal cohort included 39 patients with 68 CRLM and the external cohort 52 patients with 78 CRLM. 34/146 CRLM developed LTP after a median follow-up of 24 months (range 5-139). The median time to LTP was 8 months (range 2-22). The combined clinical-radiomics model yielded a c-statistic of 0.47 (95%CI 0.30-0.64) in the internal cohort and 0.50 (95%CI 0.38-0.62) in the external cohort, compared to 0.78 (95%CI 0.65-0.87) in the previously published original cohort. The radiomics model yielded c-statistics of 0.46 (95%CI 0.29-0.63) and 0.39 (95%CI 0.28-0.52), and the clinical model 0.51 (95%CI 0.34-0.68) and 0.51 (95%CI 0.39-0.63) in the internal and external cohort, respectively. CONCLUSION: The previously published results for prediction of LTP after thermal ablation of CRLM using clinical and radiomics models were not reproducible in independent internal and external validation. CLINICAL RELEVANCE STATEMENT: Local tumour progression after thermal ablation of CRLM cannot yet be predicted with the use of CT radiomics of the ablation zone and peri-ablational rim. These results underline the importance of validation of radiomics results to test for reproducibility in independent cohorts. KEY POINTS: • Previous research suggests CT radiomics models have the potential to predict local tumour progression after thermal ablation in colorectal liver metastases, but independent validation is lacking. • In internal and external validation, the previously published models were not able to predict local tumour progression after ablation. • Radiomics prediction models should be investigated in independent validation cohorts to check for reproducibility.

Sense and nonsense of yT-staging on MRI after chemoradiotherapy in rectal cancer.

AIM: The aim of this work was to investigate the value of rectal cancer T-staging on MRI after chemoradiotherapy (ymrT-staging) in relation to the degree of fibrotic transformation of the tumour bed as assessed using the pathological tumour regression grade (pTRG) of Mandard as a standard of reference. METHOD: Twenty two radiologists, including five rectal MRI experts and 17 'nonexperts' (general/abdominal radiologists), evaluated the ymrT stage on the restaging MRIs of 90 rectal cancer patients after chemoradiotherapy. The ymrT stage was compared with the final ypT stage at histopathology; the percentages of correct staging (ymrT = ypT), understaging (ymrT < ypT) and overstaging (ymrT > ypT) were calculated and compared between patients with predominant tumour at histopathology (pTRG4-5) and patients with predominant fibrosis (pTRG1-3). Interobserver agreement (IOA) was computed using Krippendorff's alpha. RESULTS: Average ymrT/ypT stage concordance was 48% for the experts and 43% for the nonexperts; ymrT/ypT stage concordance was significantly higher in the pTRG4-5 subgroup (58% vs. 41% for the pTRG1-3 group; p = 0.01), with the best results for the MRI experts. Overstaging was the main source of error, especially in the pTRG1-3 subgroup (average overstaging rate 38%-44% vs. 13%-55% in the pTRG4-5 subgroup). IOA was higher for the expert versus nonexpert readers (α = 0.67 vs. α = 0.39). CONCLUSIONS: ymrT-staging is moderately accurate; accuracy is higher in poorly responding patients with predominant tumour but low in good responders with predominant fibrosis, resulting in significant overstaging. Radiologists should shift their focus from ymrT-staging to detecting gross residual (and progressive) disease, and identifying potential candidates for organ preservation who would benefit from further clinical and endoscopic evaluation to guide final treatment planning.

Development and multicenter validation of a multiparametric imaging model to predict treatment response in rectal cancer.

OBJECTIVES: To develop and validate a multiparametric model to predict neoadjuvant treatment response in rectal cancer at baseline using a heterogeneous multicenter MRI dataset. METHODS: Baseline staging MRIs (T2W (T2-weighted)-MRI, diffusion-weighted imaging (DWI) / apparent diffusion coefficient (ADC)) of 509 patients (9 centres) treated with neoadjuvant chemoradiotherapy (CRT) were collected. Response was defined as (1) complete versus incomplete response, or (2) good (Mandard tumor regression grade (TRG) 1-2) versus poor response (TRG3-5). Prediction models were developed using combinations of the following variable groups: (1) Non-imaging: age/sex/tumor-location/tumor-morphology/CRT-surgery interval (2) Basic staging: cT-stage/cN-stage/mesorectal fascia involvement, derived from (2a) original staging reports, or (2b) expert re-evaluation (3) Advanced staging: variables from 2b combined with cTN-substaging/invasion depth/extramural vascular invasion/tumor length (4) Quantitative imaging: tumour volume + first-order histogram features (from T2W-MRI and DWI/ADC) Models were developed with data from 6 centers (n = 412) using logistic regression with the Least Absolute Shrinkage and Selector Operator (LASSO) feature selection, internally validated using repeated (n = 100) random hold-out validation, and externally validated using data from 3 centers (n = 97). RESULTS: After external validation, the best model (including non-imaging and advanced staging variables) achieved an area under the curve of 0.60 (95%CI=0.48-0.72) to predict complete response and 0.65 (95%CI=0.53-0.76) to predict a good response. Quantitative variables did not improve model performance. Basic staging variables consistently achieved lower performance compared to advanced staging variables. CONCLUSIONS: Overall model performance was moderate. Best results were obtained using advanced staging variables, highlighting the importance of good-quality staging according to current guidelines. Quantitative imaging features had no added value (in this heterogeneous dataset). CLINICAL RELEVANCE STATEMENT: Predicting tumour response at baseline could aid in tailoring neoadjuvant therapies for rectal cancer. This study shows that image-based prediction models are promising, though are negatively affected by variations in staging quality and MRI acquisition, urging the need for harmonization. KEY POINTS: This multicenter study combining clinical information and features derived from MRI rendered disappointing performance to predict response to neoadjuvant treatment in rectal cancer. Best results were obtained with the combination of clinical baseline information and state-of-the-art image-based staging variables, highlighting the importance of good quality staging according to current guidelines and staging templates. No added value was found for quantitative imaging features in this multicenter retrospective study. This is likely related to acquisition variations, which is a major problem for feature reproducibility and thus model generalizability.

Predicting response to chemoradiotherapy in rectal cancer via visual morphologic assessment and staging on baseline MRI: a multicenter and multireader study.

PURPOSE: Pre-treatment knowledge of the anticipated response of rectal tumors to neoadjuvant chemoradiotherapy (CRT) could help to further optimize the treatment. Van Griethuysen et al. proposed a visual 5-point confidence score to predict the likelihood of response on baseline MRI. Aim was to evaluate this score in a multicenter and multireader study setting and compare it to two simplified (4-point and 2-point) adaptations in terms of diagnostic performance, interobserver agreement (IOA), and reader preference. METHODS: Twenty-two radiologists from 14 countries (5 MRI-experts,17 general/abdominal radiologists) retrospectively reviewed 90 baseline MRIs to estimate if patients would likely achieve a (near-)complete response (nCR); first using the 5-point score by van Griethuysen (1=highly unlikely to 5=highly likely to achieve nCR), second using a 4-point adaptation (with 1-point each for high-risk T-stage, obvious mesorectal fascia invasion, nodal involvement, and extramural vascular invasion), and third using a 2-point score (unlikely/likely to achieve nCR). Diagnostic performance was calculated using ROC curves and IOA using Krippendorf's alpha (α). RESULTS: Areas under the ROC curve to predict the likelihood of a nCR were similar for the three methods (0.71-0.74). IOA was higher for the 5- and 4-point scores (α=0.55 and 0.57 versus 0.46 for the 2-point score) with best results for the MRI-experts (α=0.64-0.65). Most readers (55%) favored the 4-point score. CONCLUSIONS: Visual morphologic assessment and staging methods can predict neoadjuvant treatment response with moderate-good performance. Compared to a previously published confidence-based scoring system, study readers preferred a simplified 4-point risk score based on high-risk T-stage, MRF involvement, nodal involvement, and EMVI.

MRI restaging of rectal cancer: The RAC (Response-Anal canal-CRM) analysis joint consensus guidelines of the GRERCAR and GRECCAR groups.

PURPOSE: To develop guidelines by international experts to standardize data acquisition, image interpretation, and reporting in rectal cancer restaging with magnetic resonance imaging (MRI). MATERIALS AND METHODS: Evidence-based data and experts' opinions were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts provided recommendations for reporting template and protocol for data acquisition were collected; responses were analysed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (if ≥ 80% consensus among experts) or uncertain (if < 80% consensus among experts). RESULTS: Consensus regarding patient preparation, MRI sequences, staging and reporting was attained using the RAND-UCLA Appropriateness Method. A consensus was reached for each reporting template item among the experts. Tailored MRI protocol and standardized report were proposed. CONCLUSION: These consensus recommendations should be used as a guide for rectal cancer restaging with MRI.

MRI anatomy of the rectum: key concepts important for rectal cancer staging and treatment planning.

A good understanding of the MRI anatomy of the rectum and its surroundings is pivotal to ensure high-quality diagnostic evaluation and reporting of rectal cancer. With this pictorial review, we aim to provide an image-based overview of key anatomical concepts essential for treatment planning, response evaluation and post-operative assessment. These concepts include the cross-sectional anatomy of the rectal wall in relation to T-staging; differences in staging and treatment between anal and rectal cancer; landmarks used to define the upper and lower boundaries of the rectum; the anatomy of the pelvic floor and anal canal, the mesorectal fascia, peritoneum and peritoneal reflection; and guides to help discern different pelvic lymph node stations on MRI to properly stage regional and non-regional rectal lymph node metastases. Finally, this review will highlight key aspects of post-treatment anatomy, including the assessment of radiation-induced changes and the evaluation of the post-operative pelvis after different surgical resection and reconstruction techniques.

Comparison of MRI response evaluation methods in rectal cancer: a multicentre and multireader validation study.

OBJECTIVES: To compare four previously published methods for rectal tumor response evaluation after chemoradiotherapy on MRI. METHODS: Twenty-two radiologists (5 rectal MRI experts, 17 general/abdominal radiologists) retrospectively reviewed the post-chemoradiotherapy MRIs of 90 patients, scanned at 10 centers (with non-standardized protocols). They applied four response methods; two based on T2W-MRI only (MRI tumor regression grade (mrTRG); split-scar sign), and two based on T2W-MRI+DWI (modified-mrTRG; DWI-patterns). Image quality was graded using a 0-6-point score (including slice thickness and in-plane resolution; sequence angulation; DWI b-values, signal-to-noise, and artefacts); scores < 4 were classified below average. Mixed model linear regression was used to calculate average sensitivity/specificity/accuracy to predict a complete response (versus residual tumor) and assess the impact of reader experience and image quality. Group interobserver agreement (IOA) was calculated using Krippendorff's alpha. Readers were asked to indicate their preferred scoring method(s). RESULTS: Average sensitivity/specificity/accuracy was 57%/64%/62% (mrTRG), 36%/79%/66% (split-scar), 40%/79%/67% (modified-mrTRG), and 37%/82%/68% (DWI-patterns); mrTRG showed higher sensitivity but lower specificity and accuracy (p < 0.001) compared to the other methods. IOA was lower for the split scar method (0.18 vs. 0.39-0.43). Higher reader experience had a significant positive effect on diagnostic performance and IOA (except for the split scar sign); below-average imaging quality had a significant negative effect on diagnostic performance. DWI pattern was selected as the preferred method by 73% of readers. CONCLUSIONS: Methods incorporating DWI showed the most favorable results when combining diagnostic performance, IOA, and reader preference. Reader experience and image quality clearly impacted diagnostic performance emphasizing the need for state-of-the-art imaging and dedicated radiologist training. KEY POINTS: • In a multireader study comparing 4 MRI methods for rectal tumor response evaluation, those incorporating DWI showed the best results when combining diagnostic performance, IOA, and reader preference. • The most preferred method (by 73% of readers) was the "DWI patterns" approach with an accuracy of 68%, high specificity of 82%, and group IOA of 0.43. • Reader experience level and MRI quality had an evident effect on diagnostic performance and IOA.

Significant improvement after training in the assessment of lateral compartments and short-axis measurements of lateral lymph nodes in rectal cancer.

OBJECTIVES: In patients with rectal cancer, the size and location of lateral lymph nodes (LLNs) are correlated to increased lateral local recurrence rates. Sufficient knowledge and accuracy when measuring these features are therefore essential. The objective of this study was to evaluate the variation in measurements and anatomical classifications of LLNs before and after training. METHODS: Fifty-three Dutch radiologists examined three rectal MRI scans and completed a questionnaire. Presence, location, size, and suspiciousness of LLNs were reported. This assessment was repeated after a 2-hour online training by the same radiologists with the same three cases plus three additional cases. Three expert radiologists independently evaluated these 6 cases and served as the standard of reference. RESULTS: Correct identification of the anatomical location improved in case 1 (62 to 77% (p = .077)) and in case 2 (46 to 72% (p = .007)) but decreased in case 3 (92 to 74%, p = .453). Compared to the first three cases, cases 4, 5, and 6 all had a higher initial consensus of 73%, 79%, and 85%, respectively. The mean absolute deviation of the short-axis measurements in cases 1-3 were closer-though not significantly-to the expert reference value after training with reduced ranges and standard deviations. Subjective determination of malignancy had a high consensus rate between participants and experts. CONCLUSION: Though finding a high consensus rate for determining malignancy of LLNs, variation in short-axis measurements and anatomical location classifications were present and improved after training. Adequate training would support the challenges involved in evaluating LLNs appropriately. KEY POINTS: • Variation was present in the assessment of the anatomical location and short-axis size of lateral lymph nodes. • In certain cases, the accuracy of short-axis measurements and anatomical location, when compared to an expert reference value, improved after a training session. • Consensus before and after training on whether an LLN was subjectively considered to be suspicious for malignancy was high.

Features on Endoscopy and MRI after Treatment with Contact X-ray Brachytherapy for Rectal Cancer: Explorative Results.

After neoadjuvant (chemo)radiotherapy for rectal cancer, contact X-ray brachytherapy (CXB) can be applied aiming at organ preservation. This explorative study describes the early features on endoscopy and MRI after CXB. Patients treated with CXB following (chemo)radiotherapy and a follow-up of ≥12 months were selected. Endoscopy and MRI were performed every 3 months. Expert readers scored all the images according to structured reporting templates. Thirty-six patients were included, 15 of whom obtained a cCR. On endoscopy, the most frequently observed feature early in follow-up was an ulcer, regardless of whether patients developed a cCR. A flat, white scar and tumor mass were common at 6 months. Focal tumor signal on T2W-MRI and mass-like high signal on DWI were generally absent in patients with a cCR. An ulceration on T2W-MRI and "reactive" mucosal signal on DWI were observed early in follow-up regardless of the final tumor response. The distinction between a cCR and a residual tumor generally can be made at 6 months. Features associated with a residual tumor are tumor mass on endoscopy, focal tumor signal on T2W-MRI, and mass-like high signal on DWI. Early recognition of these features is necessary to identify patients who will not develop a cCR as early as possible.

Defining near-complete response following (chemo)radiotherapy for rectal cancer: systematic review.

BACKGROUND: A uniform definition of a clinical near-complete response (near-CR) after neoadjuvant (chemo)radiotherapy for rectal cancer is lacking. A clear definition is necessary for uniformity in clinical practice and trial enrolment for organ-preserving treatments. This review aimed to provide an overview of the terminology, criteria, and features used in the literature to define a near-CR. METHODS: A systematic review was performed based on the PRISMA statement. PubMed and Embase were searched up to May 2021 to identify the terminology, criteria, and features used to define a near-CR after (chemo)radiotherapy for rectal cancer. Studies with no clear cut-off point between a cCR and near-CR, studies using Response Evaluation Criteria In Solid Tumours, and studies including only complete responders were excluded. RESULTS: A total of 1876 articles were found, of which 23 were included. Patients were managed by watchful waiting and/or additional local treatment in 11 and 17 of 23 studies respectively. Response evaluation included digital rectal examination (DRE) and/or endoscopy with MRI in 18 studies. The majority of studies used the term 'near-complete response'. In most studies, minor irregularities or a smooth induration with DRE and a small flat ulcer on endoscopy were considered to indicate a near-CR. On MRI, five studies used features (obvious downstaging with or without heterogeneous/irregular fibrosis on T2-weighted MRI or small spot of high signal on diffusion-weighted imaging), five studies used TNM criteria (ycT2), and four used magnetic resonance tumour regression grade (mrTRG) (mrTRG1-2/mrTRG2) to describe a near-CR. CONCLUSION: The terminology, criteria, and features used to describe a near-CR vary substantially, which can partly be explained by the different treatment strategies patients are selected for (watchful waiting or additional local treatment). A reproducible definition of near-CR is required.

Lateral Lymph Nodes in Rectal Cancer: Do we all Think the Same? A Review of Multidisciplinary Obstacles and Treatment Recommendations.

Lateral lymph nodes in low, locally advanced, rectal cancer have proven implications for local recurrence rates, which increase drastically in the presence of persistently enlarged lateral lymph nodes. These clinical implications warrant a thorough understanding of lateral nodal disease with awareness and knowledge from all three specialties involved - radiology, radiation oncology, and surgery - to ensure proper treatment. Relevant literature for each specialty, including all current guidelines and perspectives, were examined. Variations in definitions and treatment paradigms were evaluated. There is still no consensus for the standardized treatment of lateral nodal disease. Each discipline works according to their own available evidence, but relevant data are scarce. Current international guidelines and standard recommendations for the diagnostics and treatment of lateral lymph nodes are lacking. This results in differing perspectives and interpretations between the disciplines which can lead to challenging communication in an area where multidisciplinary collaboration is essential. This review addresses this by presenting the current evidence, perspectives and practices of each specialty and makes suggestions for each phase of the diagnostic and treatment process for patients with lateral nodal disease. By doing this, steps are taken toward achieving international consensus, and multidisciplinary collaboration.

Current controversies in TNM for the radiological staging of rectal cancer and how to deal with them: results of a global online survey and multidisciplinary expert consensus.

OBJECTIVES: To identify the main problem areas in the applicability of the current TNM staging system (8th ed.) for the radiological staging and reporting of rectal cancer and provide practice recommendations on how to handle them. METHODS: A global case-based online survey was conducted including 41 image-based rectal cancer cases focusing on various items included in the TNM system. Cases reaching < 80% agreement among survey respondents were identified as problem areas and discussed among an international expert panel, including 5 radiologists, 6 colorectal surgeons, 4 radiation oncologists, and 3 pathologists. RESULTS: Three hundred twenty-one respondents (from 32 countries) completed the survey. Sixteen problem areas were identified, related to cT staging in low-rectal cancers, definitions for cT4b and cM1a disease, definitions for mesorectal fascia (MRF) involvement, evaluation of lymph nodes versus tumor deposits, and staging of lateral lymph nodes. The expert panel recommended strategies on how to handle these, including advice on cT-stage categorization in case of involvement of different layers of the anal canal, specifications on which structures to include in the definition of cT4b disease, how to define MRF involvement by the primary tumor and other tumor-bearing structures, how to differentiate and report lymph nodes and tumor deposits on MRI, and how to anatomically localize and stage lateral lymph nodes. CONCLUSIONS: The recommendations derived from this global survey and expert panel discussion may serve as a practice guide and support tool for radiologists (and other clinicians) involved in the staging of rectal cancer and may contribute to improved consistency in radiological staging and reporting. KEY POINTS: • Via a case-based online survey (incl. 321 respondents from 32 countries), we identified 16 problem areas related to the applicability of the TNM staging system for the radiological staging and reporting of rectal cancer. • A multidisciplinary panel of experts recommended strategies on how to handle these problem areas, including advice on cT-stage categorization in case of involvement of different layers of the anal canal, specifications on which structures to include in the definition of cT4b disease, how to define mesorectal fascia involvement by the primary tumor and other tumor-bearing structures, how to differentiate and report lymph nodes and tumor deposits on MRI, and how to anatomically localize and stage lateral lymph nodes. • These recommendations may serve as a practice guide and support tool for radiologists (and other clinicians) involved in the staging of rectal cancer and may contribute to improved consistency in radiological staging and reporting.

The sigmoid take-off as a landmark to distinguish rectal from sigmoid tumours on MRI: Reproducibility, pitfalls and potential impact on treatment stratification.

PURPOSE: The sigmoid take-off (STO) was recently introduced as a preferred landmark, agreed upon by expert consensus recommendation, to discern rectal from sigmoid cancer on imaging. Aim of this study was to assess the reproducibility of the STO, explore its potential treatment impact and identify its main interpretation pitfalls. METHODS: Eleven international radiologists (with varying expertise) retrospectively assessed n = 155 patients with previously clinically staged upper rectal/rectosigmoid tumours and re-classified them using the STO as completely below (rectum), straddling the STO (rectosigmoid) or completely above (sigmoid), after which scores were dichotomized as rectum (below/straddling STO) and sigmoid (above STO), being the clinically most relevant distinction. A random subset of n = 48 was assessed likewise by 6 colorectal surgeons. . RESULTS: Interobserver agreement (IOA) for the 3-category score ranged from κ0.19-0.82 (radiologists) and κ0.32-0.72 (surgeons), with highest scores for the most experienced radiologists (κ0.69-0.76). Of the 155 cases, 44 (28%) were re-classified by ≥ 80% of radiologists as sigmoid cancers; 36 of these originally received neoadjuvant treatment which in retrospect might have been omitted if the STO had been applied. Main interpretation pitfalls were related to anatomical variations, borderline cases near the STO and angulation of axial imaging planes. CONCLUSIONS: Good agreement was reached for experienced radiologists. Despite considerable variation among less-expert readers, use of the STO could have changed treatment in ±1/4 of patients in our cohort. Identified interpretation pitfalls may serve as a basis for teaching and to further optimize MR protocols.