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MRI for Detection of Extramural Vascular Invasion in Rectal Cancer

Neil J. Smith1, Oliver Shihab2, Abed Arnaout3, R. Ian Swift1 and Gina Brown4

1 Department of Surgery, Mayday University Hospital, Croydon, United Kingdom.
2 Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke, United Kingdom.
3 Department of Histopathology, Mayday University Hospital, Croydon, United Kingdom.
4 Department of Clinical Radiology, Royal Marsden National Health Service Trust, Downs Rd., Sutton, Surrey SM2 5PT, United Kingdom.


Figure 1
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  		Fig. 1 —79-year-old man with bulky upper rectal tumor. T2-weighted sagittal MR image shows serpiginous structure (white arrow) with very low signal intensity. This appearance is typical of major vessel, in this example, superior rectal vein. Smaller tributaries (black arrow) also are tortuous but of high signal intensity.

 

Figure 2
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  		Fig. 2 —54-year-old man with low rectal tumor. T2-weighted axial MR image shows serpiginous vessels radiating outward from edge of muscularis propria into mesorectal fat.

 

Figure 3
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  		Fig. 3 —50-year-old man with rectal tumor. Sagittal T2-weighted MR image shows paired veins (arrows) running posteriorly in mesorectum distal to confluence with superior rectal vein.

 

Figure 4
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  		Fig. 4 —59-year-old woman with upper rectal tumor. Axial T2-weighted MR image below level of tumor clearly shows right middle rectal vein (black arrow). Origin of left middle rectal vein (white arrow) emerging from edge of muscularis also is evident.

 

Figure 5
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  		Fig. 5A —70-year-old woman with rectal cancer. Axial MR image shows multiple small nodular protrusions (arrows) of intermediate signal intensity (MRI extramural vascular invasion score 1).

 

Figure 6
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  		Fig. 5B —70-year-old woman with rectal cancer. Histopathologic photograph of megablock section corresponding to A shows circumferential involvement of entire wall extending into perirectal fat. Nodular protrusions (arrows) are not associated with vascular invasion. (H and E, x1.5)

 

Figure 7
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  		Fig. 6A —61-year-old man with rectal cancer. Adjacent axial MR images show multiple areas of stranding extending radially from tumor edge. Some stranding is simply desmoplasia, defined by fine low-signal-intensity spikes evident in C. However, at least one example of more irregular nodular intermediate-signal-intensity stranding (arrow, B) represents MRI extramural vascular invasion score 3.

 

Figure 8
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  		Fig. 6B —61-year-old man with rectal cancer. Adjacent axial MR images show multiple areas of stranding extending radially from tumor edge. Some stranding is simply desmoplasia, defined by fine low-signal-intensity spikes evident in C. However, at least one example of more irregular nodular intermediate-signal-intensity stranding (arrow, B) represents MRI extramural vascular invasion score 3.

 

Figure 9
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  		Fig. 6C —61-year-old man with rectal cancer. Histopathologic photograph of megablock section corresponding to A and B shows circumferential tumor extending into perirectal fat in posterior aspect. Focal evidence of extramural vascular invasion (arrows) is present. (H and E, x1.5)

 

Figure 10
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  		Fig. 7A —82-year-old woman with polypoid tumor of rectum. Axial T2-weighted MR image shows vein emerging from edge of bowel wall very close to base of tumor, but vessel is of normal caliber, and no definite tumor signal intensity appears within it (MRI extramural vascular invasion score 2).

 

Figure 11
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  		Fig. 7B —82-year-old woman with polypoid tumor of rectum. Photograph of histopathologic section corresponding to A shows invasive moderately differentiated adenocarcinoma arising in severely dysplastic tubulovillous adenoma. Tumor invades posterior wall of rectum, extending into perirectal fat. Focal microscopic evidence of vascular invasion (arrow) is beyond resolution of MRI. (H and E, x2.5)

 

Figure 12
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  		Fig. 8 —61-year-old man with rectal tumor. Axial T2-weighted MR image shows multiple small veins containing tumor of intermediate signal intensity. One vessel (white arrow) is slightly expanded by tumor, and another (gray arrow) is of normal caliber (MRI extramural vascular invasion score 3).

 

Figure 13
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  		Fig. 9 —53-year-old woman with rectosigmoid tumor. Sagittal T2-weighted MR image shows gross nodular expansion of vessel (white arrow) draining into superior rectal vein (gray arrows). Tumor of intermediate signal intensity is evident within superior rectal vein at this level, slightly expanding it. Normal-caliber vessel containing signal void extends inferiorly beyond expanded section (MRI extramural vascular invasion score 4).

 

Figure 14
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  		Fig. 10A —75-year-old man with rectal cancer. Coronal MR image shows tumor growing along line of vein (white arrow) on right side forming expanding nodule (black arrow). Normal vein (gray arrows) also is present (MRI extramural vascular invasion score 4).

 

Figure 15
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  		Fig. 10B —75-year-old man with rectal cancer. Photograph of histopathologic section confirms presence of extramural deposit (arrow), but its relation to vascular structure cannot be appreciated in this axial section. Consequently, any extramural vascular invasion can easily be overlooked by pathologist, who does not have benefit of multiple contiguous H and E–stained sections through tumor. (H and E, x1.5)

 

Figure 16
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  		Fig. 10C —75-year-old man with rectal cancer. Photograph of same histologic section as B specially treated with Van Gieson stain because of lack of clarity in B. Stain colors elastic tissue black, collagen red, and other tissue yellow, making it clear that extramural vascular invasion is present. Tumor cells are evident in lumen of small venule (white arrow). Adjacent arteriole (black arrow) does not contain tumor.

 

Figure 17
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  		Fig. 10D —75-year-old man with rectal cancer. Medium-power view shows incomplete rim of collagen (arrows) surrounding tumor. Rim likely represents remnant of wall of larger vein.

 

Figure 18
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  		Fig. 11A —49-year-old man with rectal tumor. Photograph of histopathologic section shows tumor nodule apparently extending laterally from right side of primary tumor. Extramural vascular invasion within nodule is not visible. (H and E)

 

Figure 19
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  		Fig. 11B —49-year-old man with rectal tumor. Serial ascending axial MR images through tumor suggest nodule lies within tubular structure running parallel to bowel wall and signal void (arrow, D) indicating structure is vein (MRI extramural vascular invasion score 4).

 

Figure 20
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  		Fig. 11C —49-year-old man with rectal tumor. Serial ascending axial MR images through tumor suggest nodule lies within tubular structure running parallel to bowel wall and signal void (arrow, D) indicating structure is vein (MRI extramural vascular invasion score 4).

 

Figure 21
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  		Fig. 11D —49-year-old man with rectal tumor. Serial ascending axial MR images through tumor suggest nodule lies within tubular structure running parallel to bowel wall and signal void (arrow, D) indicating structure is vein (MRI extramural vascular invasion score 4).

 

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