Diffusion-weighted MRI to assess response to chemoradiotherapy in rectal cancer: main interpretation pitfalls and their use for teaching

Doenja M. J. Lambregts, Miriam M. van Heeswijk, Andrea Delli Pizzi, Saskia G. C. van Elderen, Luisa Andrade, Nicky H. G. M. Peters, Peter A. M. Kint, Margreet Osinga-de Jong, Shandra Bipat, Rik Ooms, Max J. Lahaye, Monique Maas, Geerard L. Beets, Frans C. H. Bakers, Regina G. H. Beets-Tan

To establish the most common image interpretation pitfalls for non-expert readers using diffusion-weighted imaging (DWI) to assess response to chemoradiotherapy in patients with rectal cancer and to explore the use of these pitfalls in an expert teaching setting. Two independent non-expert readers (R1 and R2) scored the restaging DW MRI scans (b1,000 DWI, in conjunction with ADC maps and T2-W MRI scans for anatomical reference) in 100 patients for the likelihood of a complete response versus residual tumour using a five-point confidence score. The readers received expert feedback and the final response outcome for each case. The supervising expert documented any potential interpretation errors/pitfalls discussed for each case to identify the most common pitfalls. The most common pitfalls were the interpretation of low signal on the ADC map, small susceptibility artefacts, T2 shine-through effects, suboptimal sequence angulation and collapsed rectal wall. Diagnostic performance (area under the ROC curve) was 0.78 (R1) and 0.77 (R2) in the first 50 patients and 0.85 (R1) and 0.85 (R2) in the final 50 patients. Five main image interpretation pitfalls were identified and used for teaching and feedback. Both readers achieved a good diagnostic performance with an AUC of 0.85. • Fibrosis appears hypointense on an ADC map and should not be mistaken for tumour. • Susceptibility artefacts on rectal DWI are an important potential pitfall. • T2 shine-through on rectal DWI is an important potential pitfall. • These pitfalls are useful to teach non-experts how to interpret rectal DWI.