Javaria Aleem, Pir Abdul Ahad Qureshi, Muhammad Talha Yaseen, Kashif Siddique, Amna Babar




Rectal cancer is amongst the most common gastrointestinal tumors. MRI is required at diagnosis followed by with or without neoadjuvant therapy and surgery. Accurate staging is not only important for predicting prognosis but also determine the risk of recurrence. Independent prognostic factors like extramural invasion (EMI) into mesorectal fat, extramural vascular invasion (EMVI) and circumfrential resection margins are also very important and needs to be addressed in MRI reports as presence of any of these factors may change the management plan entirely.


Objective: The purpose of this study is to determine accuracy of baseline MRI in detecting extramural tumor extension and extramural vascular invasion in rectal tumors taking pathological staging as gold standard.


Materials and Methods:

The study was approved by our institutional review board which waived the requirement for informed consent. The clinical data of all the patients treated for rectal carcinoma at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore between 1st December 2015 and 30th November 2017 were retrospectively evaluated for the presence of EMI and EMVI by rectal carcinoma on MRI. EMVI was then graded over 5 point scale. Findings of MRI were then correlated with histological findings and were labelled as positive or negative on the basis of per-operative presence or absence of EMI and EMVI.



117 patients were included in this study. Out of these 117; 111 patients (94.9 %) received pre-operative chemoradiotherapy. 6 patients (5.1%) did not receive pre-operative chemotherapy and underwent upfront surgery. On MRI EMVI (mr-EMVI) was present in 22(18.8%) patients while on pathology it was present in 19 (16.2%) patients. A close association was observed between the baseline mr-EMVI status and the extent of mesorectal invasion. Stage T3c tumors were the most frequent to present EMVI i.e. 54.5% (12/22). On baseline MRI mr-EMVI was predominantly present in tumors located in mid rectum (86.4%; 19/22). EMI was also seen frequently in stage T3c patients (i-e 45/117;38.5%). Overall MRI has accuracy in T3 disease was found to be 76.14 %


Baseline MRI is highly effective imaging modality to evaluate pre-operative EMI and EMVI in rectal cancers which have a significant independent impact on the management plan.

Keywords: Rectal cancer, Extramural invasion, Extramural vascular invasion, MRI.

Full Text:



Smith NJ, Barbachano Y, Norman AR, Swift RI, Abulafi AM, Brown G. Prognostic significance of magnetic resonance imaging-detected extramural vascular invasion in rectal cancer. Br J Surg. 2008 Feb;95(2):229-36.

Brown G, Radcliffe AG, Newcombe RG, Dallimore NS, Bourne MW, Williams GT. Preoperative assessment of prognostic factors in rectal cancerusing high-resolution magnetic resonance imaging. Br J Surg. 2003 Mar;90(3):355-64.

Talbot IC, Ritchie S, Leighton MH, Hughes AO, Bussey HJ, Morson BC. The clinical significance of invasion of veins by rectal cancer. Br J Surg. 1980 Jun;67(6):439-42.

Betge J, Pollheimer MJ, Lindtner RA, Kornprat P, Schlemmer A, Rehak P, et al. Intramural and extramural vascular invasion in colorectal cancer: prognostic significance and quality of pathology reporting. Cancer. 2012 Feb 1;118(3):628-38. doi: 10.1002/cncr.26310. Epub 2011 Jul 12.

Bokey EL, Chapuis PH, Dent OF, Newland RC, Koorey SG, Zelas PJ, et al. Factors affecting survival after excision of the rectum for cancer: a multivariate analysis. Dis Colon Rectum. 1997 Jan;40(1):3-10.

Maier A, Fuchsjager M. Preoperative staging of rectal cancer. Eur J Radiol. 2003 Aug;47(2):89-97.

Iafrate F, Laghi A, Paolantonio P, Rengo M, Mercantini P, Ferri M, et al. Preoperative staging of rectal cancer with MR Imaging: correlation with surgical and histopathologic findings. Radiographics. 2006 May-Jun;26(3):701-14.

Halperin EC, Perez CA, Brady LW. Perez and Brady's principles and practice of radiation oncology. Lippincott Williams & Wilkins.(2008) ISBN:078176369X.

Huh JW, Lee JH, Kim HR, Kim YJ. Prognostic significance of lymphovascular or perineural invasion in patients with locally advanced colorectal cancer. Am J Surg. 2013 Nov;206(5):758-63. doi: 10.1016/j.amjsurg.2013.02.010. Epub 2013 Jul 5.

Smith N, Brown G. Preoperative staging of rectal cancer. Acta Oncol. 2008;47 (1): 20-31. doi:10.1080/02841860701697720

Yu SK, Tait D, Chau I, Brown G. MRI predictive factors for tumor response in rectal cancer following neoadjuvant chemoradiation therapy--implications for induction chemotherapy? Int J Radiat Oncol Biol Phys. 2013 Nov 1;87(3):505-11.

Jhaveri KS, Hosseini-Nik H, Thipphavong S, Assarzadegan N, Menezes RJ, Kennedy ED, et al. MRI Detection of Extramural Venous Invasion in Rectal Cancer: Correlation with Histopathology Using Elastin Stain. AJR Am J Roentgenol. 2016 Apr;206(4):747-55. doi: 10.2214/AJR.15.15568. Epub 2016 Mar 2.

Beets-tan RG, Beets GL. Rectal cancer: review with emphasis on MR imaging. Radiology. 2004 Aug;232(2):335-46.

MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993 Feb 20;341(8843):457-60.

Brown G. Local radiological staging of rectal cancer. Clin Radiol. 2004 Mar;59(3):213-4.

Goh V, Halligan S, Bartram CI. Local radiological staging of rectal cancer. Clin Radiol. 2004 Mar;59(3):215-26.

Beets-Tan RG, Beets GL, Vliegen RF, Kessels AG, Van Boven H, De Bruine A, et al. Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet. 2001 Feb 17;357(9255):497-504.

Akasu T, Kondo H, Moriya Y, Sugihara K, Gotoda T, Fujita S, et al. Endorectal ultrasonography and treatment of early stage rectal cancer. World J Surg. 2000 Sep;24(9):1061-8.

Chen ET, Mohiuddin M, Brodovsky H, Fishbein G, Marks G. Downstaging of advanced rectal cancer following combined preoperative chemotherapy and high dose radiation. Int J Radiat Oncol Biol Phys. 1994 Aug 30;30(1):169-75.


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