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Background  Diffusion-weighted imaging (DWI) has shown great value in rectal cancer imaging. However, traditional DWI with echo-planar imaging (DW-EPI) often suffers from geometrical distortions. We applied a three-dimensional diffusion-prepared stimulated-echo turbo spin-echo sequence (DPsti-TSE), allowing geometrically undistorted rectal DWI. We compared DPsti-TSE with DW-EPI for locally advanced rectal cancer DWI.    Methods  For 33 prior-to-treatment patients, DWI images of the rectum were acquired with DPsti-TSE and DW-EPI at 3 T using b-values of 200 and 1000 s/mm 2 . Two radiologists conducted a blinded scoring of the images considering nine aspects of image quality and anatomical quality. Tumour apparent diffusion coefficient (ADC) and distortions were compared quantitatively.    Results  DPsti-TSE scored significantly better than DW-EPI in rectum distortion ( p =  0.005) and signal pileup ( p =  0.001). DPsti-TSE had better tumour Dice similarity coefficient compared to DW-EPI (0.84  versus  0.80,  p =  0.010). Tumour ADC values were higher for DPsti-TSE compared to DW-EPI (1.47  versus  0.86 × 10 -3  mm 2 /s,  p <  0.001). Radiologists scored DPsti-TSE significantly lower than DW-EPI on aspects of overall image quality ( p =  0.001), sharpness ( p <  0.001), quality of fat suppression ( p <  0.001), tumour visibility ( p =  0.009), tumour conspicuity ( p =  0.010) and rectum wall visibility ( p =  0.005).    Conclusions  DPsti-TSE provided geometrically less distorted rectal cancer diffusion-weighted images. However, the image quality of DW-EPI over DPsti-TSE was referred on the basis of several image quality criteria. A significant bias in tumour ADC values from DPsti-TSE was present. Further improvements of DPsti-TSE are needed until it can replace DW-EPI.

Locally advanced rectal cancer: 3D diffusion-prepared stimulated-echo turbo spin-echo versus 2D diffusion-weighted echo-planar imaging