The split scar sign as an indicator of sustained complete response after neoadjuvant therapy in rectal cancer

Inês Santiago, Maria Barata, Nuno Figueiredo, Oriol Parés, Vanessa Henriques, António Galzerano, Carlos Carvalho, Celso Matos, Richard J. Heald

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18 Citations (Scopus)


Objectives: To measure the diagnostic performance of a new radiologic pattern on restaging magnetic resonance (MR) high-resolution T2-weighted imaging (T2-WI)—the split scar sign—for the identification of sustained complete response (SCR) after neoadjuvant therapy in rectal cancer. Methods: Institutional review board approval was obtained for this retrospective study and the informed consent requirement was waived. Fifty-eight consecutive patients with rectal cancer who underwent neoadjuvant therapy were enrolled. Two radiologists blindly and independently reviewed restaging pelvic MR imaging and recorded the presence/absence of the split scar sign (mrSSS). On a second round, they also assessed the relative proportion of intermediate signal intensity on T2-WI (mrT2) and of high signal intensity on high b-value diffusion-weighted imaging (mrDWI). Endoscopic response grading records were retrieved. Qui-square test was employed in search for associations between SCR, defined as pathologic complete response or long-term recurrence-free clinical follow-up, and mrSSS, mrT2, mrDWI and endoscopy. Interobserver agreement for imaging parameters was estimated using Cohen’s kappa (k). Results: mrSSS was significantly associated with SCR, with specificity = 0.97/0.97, sensitivity = 0.52/0.64, PPV = 0.93/0.94, NPV = 0.73/0.78, and AuROC = 0.78/0.83, for observers 1/2, respectively. mrDWI was significantly associated with SCR for observer 2, with specificity = 0.76, sensitivity = 0.60, PPV = 0.65, NPV = 0.71, and AuROC = 0.69. mrT2 and endoscopy were not discriminative. Interobserver agreement was substantial for mrSSS (k = 0.69), moderate for mrDWI (k = 0.46), and poor for mrT2 (k = 0.17). Conclusion: The split scar sign is a simple morphologic pattern visible on restaging T2-WI which, although not sensitive, is very specific for the identification of sustained complete responders after neoadjuvant therapy in rectal cancer. Key Points: • The split scar sign is a morphologic pattern visible on high-resolution T2-weighted MR imaging in rectal cancer patients after neoadjuvant therapy. It therefore does not require any changes to standard protocol. • At first restaging pelvic MR imaging (mean: 9.1 weeks after the end of radiotherapy), the split scar sign identified patients who sustained a complete response with very high specificity (0.97) and positive predictive value (0.93–0.94). • The split scar sign has the potential to improve patient selection for “watch-and-wait” after neoadjuvant therapy in rectal cancer.

Original languageEnglish
JournalEuropean Radiology
Publication statusPublished - 1 Jan 2019


  • Magnetic resonance imaging
  • Neoadjuvant therapy
  • Rectal neoplasms
  • Watchful waiting


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