Aktuelle MRT-Diagnostik des Rektumkarzinoms

Zusammenfassung

Das kolorektale Karzinom ist die zweithäufigste Krebsursache mit sehr variabler Prognose. Fortschritte in der chirurgischen Therapie als auch der Wechsel von adjuvanter zur neoadjuvanten Radiochemotherapie wie auch weitere Entwicklungen in der Diagnostik haben zur Verbesserung der Prognose geführt. Die MRT konnte sich im T-Staging und in der Bestimmung des zirkumferenziellen Resektionsrands (CRM) als verlässliche Methode gegenüber der Endosonografie etablieren. Sie erlaubt die Selektion von Patienten mit ungünstigen prognostischen Faktoren, die von einer präoperativen Radio- oder Radiochemotherapie profitieren würden. Aktuell ist der Bezug des Tumors zur mesorektalen Faszie für die Therapieplanung ein noch bedeutsamerer prognostischer Faktor als das T-Staging, insbesondere für die chirurgische Therapie. Weitere relevante Faktoren sind die Infiltrationstiefe des Tumors ins perirektale Fettgewebe und die extramurale Gefäßinfiltration (EMVI) mit deutlichem Einfluss auf Therapie und Prognose. Hochauflösende MRT kann den Bezug des Tumors zur mesorektalen Faszie als CRM für die totale mesorektale Exzision (TME) vor allem für die Tumorlokalisation im oberen und mittleren Drittel sehr gut darstellen. Die Evaluation von anderen prognostischen Faktoren wie dem Lymphknotenstatus und der EMVI ist nach wie vor schwierig. Die MRT wird nicht nur zunehmend für das primäre Lokalstaging, sondern auch vermehrt zum Therapiemonitoring unter Neoadjuvanz angewandt. Die additive diffusionsgewichtete Bildgebung (DWI) ist eine interessante Option zur Vorhersage des Therapieansprechens. In der folgenden Übersicht werden die aktuelle MRT-Diagnostik und ihre Bedeutung für die Evaluation von klinisch relevanten prognostischen Faktoren vorgestellt, die zur Verbesserung von Therapie und Prognose bei Patienten mit Rektumkarzinom führen.

Abstract

Colorectal carcinoma is the second most prevalent cause for cancer, and has very variable outcomes. Advancements in surgery, the change from adjuvant to neo-adjuvant radio-chemo-therapies as well as in clinical diagnostics have improved the prognosis for patients in a multi-modal therapy concept. An accurate primary staging including a reliable prediction of the circumferential resection margin (CRM) has established MR Imaging (MRI) beside intraluminal endoscopic ultrasound (EUS). MRI facilitates the selection of patients likely to benefit from a preoperative therapy, especially in cases of unfavorable factors. Currently the relationship of the tumor to the mesorectal fascia has become a more important prognostic factor than the T-staging, particularly for surgical therapy. In addition further prognostic factors like the depth of infiltration into the perirectal fat and the extramural venous infiltration (EMVI) have important impact on therapy and prognosis. High resolution MRI has proved useful in clarifying the relationship between the tumor and the mesorectal fascia, which represents the CRM at the total mesorectal excision (TME) especially in the upper and middle third. Preoperative evaluation of the other prognostic factors as well as the nodal status is still difficult. It is used increasingly not only for primary staging but also progressively for the monitoring of neoadjuvant therapy. The addition of diffusion weighted imaging (DWI) is an interesting option for the improvement of response evaluation. The following overview provides an introduction of MRI diagnosis as well as its importance for the evaluation of the clinically relevant prognostic factors leading to an improvement of therapy and prognosis of patients with rectal carcinoma.

Key words

MR-imaging - rectum - staging - pelvis

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