MRI predicts curative resection in rectal cancer

MERCURY Study Group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ 2006; 333: 779.

in a nutshell
Colorectal cancer remains the second commonest cause of cancer death. Curative therapy for rectal cancer relies on the technically demanding total mesorectal excision (TME). Histopathological examination of surgical specimens shows a strong correlation between clear circumferential resection margins and risk of local recurrence. Pre-operative radio- or chemoradiotherapy decreases the rate of local recurrence by reducing tumour proximity to these margins and therefore increasing the likelihood of complete excision. This paper demonstrates the use of MRI in the pre-operative assessment of the involvement of margins and therefore enable better planning of preoperative therapy and subsequent surgery. Eleven colorectal units recruited 408 consecutive patients with rectal cancer. The accuracy of pre-operative MRI to predict a curative resection based on presence or absence of tumour at the resection margins was assessed. Three hundred and eleven patients underwent primary surgery. The prediction accuracy for a clear margin was 91% (88-94% CI). In those who underwent pre-operative radio- or chemoradiotherapy, the accuracy was 77% (6986% CI).

the verdict
MRI should form part of the pre-operative MDT decision-making process for treatment of rectal cancer It is the best investigation for predicting tumour involvement at the resection margin and is more accurate than digital rectal examination More work needs to be done to understand the of the remainder rather than direct spread of the tumour. However, the impact on recurrence of this special sub-group has not yet been established. It is heartening to see that such good results for surgical excision together with consistent imaging and histopathological interpretation can be achieved in a reproducible fashion across many centres. This does much to support the further development of optimal cancer treatment through standardisation and quality control by way of dedicated workshops promoting best-practice, whatever the specialty. affect of pre-operative therapy on the subsequent tissue appearances of MRI investigations. Edward Fitzgerald edwardfitzgerald@doctors. org.uk Austin G Acheson Austin.Acheson@nottingham. ac.uk

second opinion
Three hundred and forty nine patients underwent surgery having clear resection margins predicted by MRI. Of these, 327 had clear margins in the surgical specimen (94%, 9196% CI). Three hundred and fifty four patients had clear margin on histopathology. Of these, 327 were predicted by MRI (92%, 89-95% CI). This study confirms our belief that MRI is the gold standard staging investigation for rectal cancers. The majority of UK centres have already adopted this staging tool for predicting a surgically clear margin. A number of patients in this investigation had a predicted involved margin on MRI but clear margins on histopathology but this certainly reflects the benefits of aggressive preoperative oncological therapy on tumour shrinkage. The study does have limitations and perhaps the most alarming is that approximately 40% (22/54) of patients with involved margins had not been predicted by preoperative MRI. However, 50% of these patients had intraoperative perforations due to presumed technically difficult surgery and involved margins could obviously not be predicted in such cases. Identification of involved lymph nodes within 1mm of the resection margin accounted for the majority
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