The document discusses the management and radiology of diffuse gliomas and rectal cancer. It provides guidance on staging rectal cancer with MRI, including identifying relevant anatomical structures and assessing tumor involvement. Assessment parameters are outlined for the site, size, circumference involvement, depth of invasion and nodal staging. Guidelines are provided for contouring the mesorectum and reporting MRI findings in a structured format.

1. MANAGEMENT OF DIFFUSE GLIOMAS
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DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FAROI(USA),PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam
drkcpatro@gmail.com M-9160470564
RADIOLOGY OF CANCER RECTUM

2. Slow my flow
• Staging
• Normal structures
• Diseased rectum
• Post RT picture
• Treatment algorithm
• Contouring mesorectum
• Contouring guidelines
• References
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4. Nodal staging
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5. MRI PROTOCOL
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6. 4/30/2022 6

7. REPORTING STEPS
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8. STRUCTURED
MRI
REPORTING
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9. STRUCTURED
MRI
FORMAT
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10. Structure identification
1 Anal verge
2 Anorectal junction
3 Rectosigmoid junction
4 Parts of rectum
5 Mesorectum
6 Mesorectal fascia
7 Mucosa and sub mucosa
8 Levator ani Muscle complex
9 External sphincter
10 Internal sphincter
11 Intersphincteric space
12 Peritoneal reflection
13 Ischiorectal fossa
14 Mesorectal venous plexus
15 Puborectalis
16 Adjacent structures
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12. 4/30/2022 12

13. 4/30/2022 13

14. 1.IDENTFYING ANAL VERGE
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15. 2.ANORECTAL JUNCTION
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16. 3.RECTOSIGMOID JUNCTION
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17. 4.PARTS OF RECTUM
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18. 4/30/2022 18

19. 5.Mesorectum
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20. 4/30/2022 20
6. MRF- mesorectal fascia

21. 7.Mucosa /Submucosa/MP
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22. 8-LEVATOR ANI
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23. 9.10,11
Muscles of rectum-Internal sphincter, Intersphincteric space, External sphincter
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24. 4/30/2022 24

25. 12.PERITONEL REFLECTION- SEA GULL SIGN
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26. 4/30/2022 26

27. 4/30/2022 27

28. Ischiorectal fossa
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29. 14.Mesorectal venous plexuses
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30. 15.Puborectalis
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31. 15.Puborectalis
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32. 16.ADJACENT STRUCTURES
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33. SL NO PARAMETER INFERENCE
1 SITE
2 SIZE
3 CIRUMFERNCE INVOLVEMENT
4 CLOCK POSITION
5 TYPE OF GROWTH
6 MUCINOS VS NON-MUCINOUS
7 DISTANCE FROM ANAL VERGE
8 RELATION WITH PERITONEAL REFLECTION
9 PERIRECTAL FAT STRANDING
10 PROXIMAL OBSTRUCTION
11 DEPTH OF EXTRAMURAL INVASION
12 DISTANCE FROM MESOREACTL FASICA
13 CRM STATUS
14 RETRORECTAL AREA INVOLVEMENT
15 INTERNAL SPHICNCTER INVOLVEMENT
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34. SL NO PARAMETER INFERENCE
16 EXTERNAL SPHINCTER INVOLVEMENT
17 INTERSPHINCTERIC SPACE INVOLVEMENT
18 ISCHIORECTAL FOSSA INVOLVEMENT
19 ISCHIOANAL FOSSA INVOLVEMENT
20 ADAJCENT STRACTURE INVOLVEMENT
21 PERIRECTAL SEEDING
22 EXTRAMURAL VASCULAR INVASION
23 EMVI GRADING
24 MESORECTAL NODE
25 LEFT ILIAC NODE
26 RIGHT ILIAC NODE
27 LEFT INGUINAL NODE
28 RIGHT INGUINAL NODE
29 PARAAORTIC NODE
30 FINAL STAGING
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35. 1,2-Site /Size
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36. 3.Circumference involvement
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37. 4.Clock position
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38. 4/30/2022 38
4.Clock position

39. 5.Types of growth
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41. 6.MUCINOUS VS NON MUCINOUS
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42. Mucinous vs non mucinous growth
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44. 7.Distance from anal verge
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45. Rectum
Rectum
8.RELATION WITH PERITONEAL REFLECTION
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46. 9.Desmoplastic reaction vs tumor fat stranding
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47. 10.Proximal obstruction
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48. 11.Depth of extramural invasion
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49. 12.DISTANCE FROM MESOREACTL FASICA
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50. Threatened
MRF

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54. 13.DEFINING CRM STATUS
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55. 14.RETRORECTAL SPACE INVOLVEMENT
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56. 15/16/17-SPHINCTER COMPLEX INVOLVEMENT
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57. 4/30/2022 57

58. 18/19- Ischiorectal fossa involvement
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59. 20.ADAJCENT STRACTURE INVOLVEMENT
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61. 22.Extramural lympho-vascular invasion
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66. 23.Extramural lympho-vascular invasion grading
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67. 4/30/2022 67

68. EMVI-1
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69. EMVI-2
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70. EMVI-3
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71. EMVI-4
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72. 4/30/2022 72

73. NODAL DRAINAGE IN CANCER RECTUM
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74. 24.MESORECTAL NODE
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75. 4/30/2022 75

76. 25,26-left ant right iliac node
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77. 27,28-Inguinal node
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78. 29-Paraaortic node
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79. 30.Final Staging
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80. Risk stratification
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81. Decision making
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82. 4/30/2022 82

83. TME and TME VARIANTS
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84. Restaging
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85. RESPONSE ASSESMENT AFTER NEOADJUVANT
TREATMENT IN CANCER RECTUM
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88. 4/30/2022 88

89. Low signal on the ADC map, indicating restricted
diffusion/RESIDUAL
HIGH signal on the DWI, indicating restricted
diffusion/RESIDUAL
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90. 4/30/2022 90

91. • Example of a patient with several irregularly enlarged cN+
nodes at primary staging. After chemoradiotherapy, most nodes
have disappeared and only a small node of < 5 mm remains,
indicative of a ycN0 stage
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92. FLUID
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93. 4/30/2022 93

94. Contouring mesorectum
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1. M: Mesorectum,
2. LLN: Lateral Lymph Nodes
3. EIN: External Iliac Nodes,
4. IN: Inguinal Nodes,
5. IRF: Ischio-Rectal Fossae,
6. SC: Sphincter Complex,
7. IMA: inferior mesenteric artery,
8. SA: sigmoid artery,
9. SRA: superior rectal artery

95. 4/30/2022 95

96. • https://pubs.rsna.org/do
i/epdf/10.1148/rg.2019180
114
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97. • https://radiologyassistant.nl/abdomen/rectum/rectal-cancer-mr-staging-1
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