High-Resolution MRI of the Anatomy Important in Total Mesorectal Excision of the Rectum
Gina Brown1,2,
Alex Kirkham3,
Geraint T. Williams1,
Michael Bourne1,
Andrew G. Radcliffe1,
Joanne Sayman1,
Richard Newell4,
Chummy Sinnatamby5 and
Richard J. Heald6
1 Department of Radiology, Cardiff and the Vale NHS Trust, University of Wales
College of Medicine, Heath Park, Cardiff CF14 4XW, Wales.
2 Present address: Department of Radiology, The Royal Marsden NHS Trust, Downs
Rd., Sutton, Surrey SM2 5PT, England.
3 Department of Imaging, The Middlesex Hospital, Mortimer St., London W1T 3AA,
England.
4 Cardiff School of Biosciences, Biomedical Bldg., Cardiff University, Cardiff
CF10 3US, Wales.
5 Department of Anatomy, The Royal College of Surgeons of England, 35/43
Lincoln's Inn Fields, London WC2A 3PE, England.
6 Department of Colorectal Surgery, The Pelican Centre, North Hampshire
Hospital, Aldermaston Rd., Basingstoke, Hampshire RG24 9NA, England.
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Fig. 1. —In vivo axial T2-weighted image shows parietal fascia in
78-year-old man with adenocarcinoma. Anterolaterally, fascia (arrows)
is seen as separate low-signal-intensity layer overlying obturator internus
muscle.
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Fig. 2A. —Pelvis and retrorectal space. Photograph of hemisected
cadaveric pelvis shows retrorectal space (arrowhead), which is
limited anteriorly by mesorectal fascia (arrow).
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Fig. 2B. —Pelvis and retrorectal space. Sagittal T2-weighted fast
spin-echo image obtained in 68-year-old man with recrtal adenocarcinoma shows
posterior fascial layers of pelvis. Visceral mesorectal fascia (long solid
arrow) is lying anterior to presacral fascia (short solid
arrow). High signal deep relative to presacral fascia
(arrowhead) represents fat, and signal void of median sacral vessel
(open arrow) lies in retrorectal space.
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Fig. 3. —Sagittal T2-weighted fast spin-echo image obtained in
55-year-old woman with rectal carcinoma shows perforation of rectal tumor.
High-signal-intensity fluid is seen in retrorectal space (white
arrow). Presacral fascia (black arrow) forms posterior wall of
fluid collection.
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Fig. 4A. —Rectosacral fascia. Photograph of sagittal cadaveric
hemisected pelvis shows rectosacral fascia (arrow) running obliquely
from sacrum to posterior wall of rectum.
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Fig. 4B. —Rectosacral fascia. In vivo T2-weighted fast spin-echo image
of pelvis in 67-year-old man with rectal adenocarcinoma reveals oblique
low-signal-intensity band (arrows) extending from junction of S3 and
S4 vertebrae to posterior wall of rectum that represents rectosacral
fascia.
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Fig. 5A. —Peritoneal reflection. In photograph of sagittal cadaveric
hemisection, arrow indicates peritoneum as it is reflected from bladder onto
rectum.
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Fig. 5B. —Peritoneal reflection. In vivo sagittal T2-weighted fast
spin-echo image obtained in 78-year-old man with rectal adenocarcinoma shows
peritoneal reflection (arrows) that, in this plane, can be followed
to its point of attachment (lower arrow) over anterior surface of
rectum.
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Fig. 6. —In vivo sagittal T2-weighted fast spin-echo image of pelvis
in 56-year-old man with rectal adenocarcinoma shows peritoneal reflection as
line (arrow) of low signal intensity extending over surface of
bladder posteriorly to point of attachment on anterior surface of rectum.
Below this point, peritoneum fuses to form Denonvilliers' fascia
(arrowheads).
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Fig. 7A. —Peritoneal reflection in 74-year-old man with rectal
adenocarcinoma. In vivo axial thin-slice T2-weighted fast spin-echo image
shows peritoneal reflection as low-signal-intensity layer that attaches to
rectum with characteristic V-shaped configuration anteriorly in midline
(arrow).
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Fig. 7B. —Peritoneal reflection in 74-year-old man with rectal
adenocarcinoma. Photograph of histologic section shows point of attachment
(arrow) of peritoneal reflection to anterior portion of rectum. (H
and E)
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Fig. 8A. —Denonvilliers' fascia. Photograph of cadaveric whole-mount
histologic section (A, H and E) and corresponding cadaveric MRI
(B) show Denonvilliers' fascia as localized thickening of fascia
overlying mesorectum in midline (straight arrows). Neurovascular
bundle is seen posterolaterally relative to prostate (curved arrows).
Vessels in bundle are depicted as tiny signal void structures.
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Fig. 8B. —Denonvilliers' fascia. Photograph of cadaveric whole-mount
histologic section (A, H and E) and corresponding cadaveric MRI
(B) show Denonvilliers' fascia as localized thickening of fascia
overlying mesorectum in midline (straight arrows). Neurovascular
bundle is seen posterolaterally relative to prostate (curved arrows).
Vessels in bundle are depicted as tiny signal void structures.
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Fig. 9A. —Lateral ligament. Photograph of dissected cadaveric pelvis
(A) and diagram (B) show lateral ligament, which is constituted
by fascia around rectal nerve supply derived from inferior hypogastric plexus.
S2–S4 = sacral vertebrae 2–4.
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Fig. 9B. —Lateral ligament. Photograph of dissected cadaveric pelvis
(A) and diagram (B) show lateral ligament, which is constituted
by fascia around rectal nerve supply derived from inferior hypogastric plexus.
S2–S4 = sacral vertebrae 2–4.
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Fig. 10A. —Lateral ligament. In vivo axial T2-weighted fast spin-echo
image obtained in 65-year-old man with rectal adenocarcinoma shows middle
rectal vessels as tubular signal-void structures (arrow) forming
lateral ligament.
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Fig. 10B. —Lateral ligament. Photograph of corresponding whole-mount
histologic section reveals lateral ligament visualized as fascia around middle
rectal vessels, which are indicated by arrow. (H and E)
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Fig. 11A. —Inferior hypogastric plexus. In photograph of sagittal
dissection of cadaveric pelvis, inferior hypogastric plexus (arrow)
is shown as rectangular, fenestrated structure, 3–4 cm in
anteroposterior length.
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Fig. 11B. —Inferior hypogastric plexus. In vivo sagittal T2-weighted
fast spin-echo image obtained in 68-year-old woman with rectal adenocarcinoma
depicts inferior hypogastric plexus (arrow) as distinctive
high-signal lattice.
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Fig. 12. —Oblique axial T2-weighted image obtained at level of seminal
vesicles in 66-year-old man with rectal adenocarcinoma shows inferior
hypogastric plexus (arrow) lateral to mesorectal fascia as
high-signal-intensity slightly beaded bundles, distinguishable from vessels by
lack of flow void.
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Fig. 13. —Oblique coronal T2-weighted fast spin-echo image obtained in
68-year-old man with rectal adenocarcinoma shows beaded appearance of inferior
hypogastric plexus (arrow), which can be traced back to sacral
nerves.
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Fig. 14A. —Mesorectal fascia in cadaveric pelvis. Photograph of axial
whole-mount histologic section (A, H and E), corresponding axial
T2-weighted image (B), and decalcified histologic section (C, H
and E) show mesorectal fascia surrounding mesorectum (arrows).
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Fig. 14B. —Mesorectal fascia in cadaveric pelvis. Photograph of axial
whole-mount histologic section (A, H and E), corresponding axial
T2-weighted image (B), and decalcified histologic section (C, H
and E) show mesorectal fascia surrounding mesorectum (arrows).
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Fig. 14C. —Mesorectal fascia in cadaveric pelvis. Photograph of axial
whole-mount histologic section (A, H and E), corresponding axial
T2-weighted image (B), and decalcified histologic section (C, H
and E) show mesorectal fascia surrounding mesorectum (arrows).
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Fig. 15A. —Mesorectal fascia. Axial T2-weighted fast spin-echo image
obtained in 68-year-old man with rectal adenocarcinoma shows mesorectal fascia
as low-signal layer (arrows) surrounding high-signal-intensity
mesorectum.
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Fig. 15B. —Mesorectal fascia. Photograph of corresponding whole-mount
histologic section shows mesorectal fascia (arrows) encasing
mesorectum. Blood vessels and lymphatic tissue are seen within mesorectum. (H
and E)
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Fig. 16A. —Rectal wall. In vivo axial T2-weighted fast spin-echo image
of rectum in 42-year-old woman with rectal adenocarcinoma (A) and
photograph of corresponding histologic section (B, H and E) show layers
of rectal wall. Mucosa (short straight arrow) displays low signal
intensity, and submucosa (long straight arrow) displays high signal
intensity. Muscularis propria (curved arrows), comprising inner
circular and outer longitudinal muscle, has low signal intensity.
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Fig. 16B. —Rectal wall. In vivo axial T2-weighted fast spin-echo image
of rectum in 42-year-old woman with rectal adenocarcinoma (A) and
photograph of corresponding histologic section (B, H and E) show layers
of rectal wall. Mucosa (short straight arrow) displays low signal
intensity, and submucosa (long straight arrow) displays high signal
intensity. Muscularis propria (curved arrows), comprising inner
circular and outer longitudinal muscle, has low signal intensity.
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Copyright © 2004 by the American Roentgen Ray Society.
