Endorectal Ultrasonography Research Articles

An Elderly Patient on Warfarin With Rectal Bleeding

Question: An 83-year-old woman was admitted to the hospital with rectal bleeding. She complained about pain in her lower back because of a heavy fall at home 2 weeks before. Owing to atrial fibrillation and low cardiac output, she had been under constant treatment with phenprocoumon. On rectal examination, a soft mass was felt dorsal on supine position. Laboratory studies revealed abnormal coagulation tests with a prolonged prothrombin time (international normalized ratio, 2.5) and a slightly prolonged partial thromboplastin time of 38 seconds (normal, 24–36). The platelet count was within the normal range, and her serum creatinine was elevated (4 mg/dL). Because of severe anemia (hemoglobin, 7.5 g/dL), she received a pack of red blood cells. Ileocolonoscopy revealed massive diverticulosis of the entire colon and a 3-mm opening to the dorsal rectal wall with discharge of blood (Figure A). Computed tomography without contrast enhancement because of impaired renal function was performed, revealing a 7 × 7-cm round, liquid mass (Figure B) that could also be demonstrated by rectal endosonography (Figure C). Correlating her clinical and imaging findings, what is your diagnosis? Look on page 270 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Colonoscopy suggested a fistula of the rectum, and computed tomography showed a large presacral, retro-rectal mass consistent with a hematoma. Next, contrast-enhanced fluoroscopy was performed using a catheter inserted into the presumed rectal fistula by flexible rectoscopy, demonstrating connection of the hematoma with the rectum. Phenprocoumon was stopped, and vitamin K was given leading to normalization of the prothrombin time. The patient was started on ceftriaxone and metronidazole and underwent surgery 2 days later. Transrectal evacuation of the hematoma and irrigation with saline were performed, and the perforation site was closed by transanal suture. A corrugated drain was inserted into the rectal space and removed 5 days later. The further course was uneventful, and the patient was discharged. Anticoagulation with phenprocoumon was resumed. Systemic anticoagulation is a frequent cause of gastrointestinal bleeding, especially if predisposing conditions are present.1Ahsberg K. Höglund P. Kim W.H. et al.Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding.Scand J Gastroenterol. 2010; 45: 1404-1415Crossref PubMed Scopus (56) Google Scholar However, most studies have focused on the upper gastrointestinal tract. According to the available data, up to 40% of patients with lower gastrointestinal bleeding were under anticoagulant and/or antiplatelet therapy. The most common cause of colorectal bleeding in these patients is diverticulosis, accounting for >50% of cases. Other causes of lower gastrointestinal bleeding in patients under long-term anticoagulation include in addition, polyps, arteriovenous malformations, hemorrhoids, colorectal cancer, ulceration, and colitis/proctitis. Perirectal hematoma after rectal stapled mucosectomy for hemorrhoids and rectus sheath hematoma associated with abdominal trauma and/or anticoagulation therapy has been described previously.2Hidalgo G.L.A. Heredia B.A. Fantova M.J. et al.Perirectal haematoma and hypovolaemic shock after rectal stapled mucosectomy for haemorrhoids.Int J Colorectal Dis. 2005; 20: 471-472Crossref PubMed Scopus (18) Google Scholar, 3Klingler P.J. Wetscher G. Glaser K. et al.The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders.Sur Endosc. 1999; 13: 1129-1134Crossref PubMed Scopus (83) Google Scholar To our knowledge, however, this is the first report of a perirectal hematoma leading to severe lower gastrointestinal bleeding.

Evaluations of puberty sexual development in girls by intraluminal ultrasound

To assess the significance of intraluminal ultrasound in the diagnosis of developmental status and treatment effect in normal and idiopathic precocious puberty (ICPP) girls. Endorectal ultrasonography was used to measure the parameters of uterine length, width, thickness, cervix length, ovarian volume and maximum follicular length in normal girls and compare their differences between pre- and post-treatment by gonadotropin-releasing hormone analogues (GnRHa) in idiopathic precocious puberty girls. The ultrasonic parameters of uterus and ovary in normal girls significantly increased in average 9-year-old girls (1.87 ± 0.58) ml of uterine volume in 9-year-old group vs (1.03 ± 0.24) ml in 7-year-old group; ovarian volume (3.01 ± 2.73) ml of uterine volume in 9-year-old group vs 0.98 ± 0.36 ml in 7-year-old group. They were much greater in ICPP girls and decreased significantly at post-treatment, (1.16 ± 0.19) ml of uterus volume pre-treatment vs (1.02 ± 0.15) ml post-treatment; (2.11 ± 0.48) ml of ovarian volume pre-treatment, (1.72 ± 0.55) ml post-treatment; (1.36 ± 0.25) cm of the biggest follicular diameter pre-treatment, (1.16 ± 0.36) cm post-treatment. Endosonography is an important tool of evaluating the development status and treatment effect in normal and ICPP girls.

Bedeutung der Endoskopie und Endosonographie für das lokale Staging beim Rektumkarzinom

For rectal carcinoma the decision between primary resection, neoadjuvant therapy and local excision depends on an accurate local staging. Local staging includes digital examination, rigid rectoscopy and endorectal ultrasound (EUS). The rectal digitation allows clinical staging according to the mobility of the tumor in relation to the rectal mucosa or the rectal wall. The rigid rectoscopy determines the aboral distance of the tumor from the dentate line or the anal verge. The endorectal ultrasound determines the pre-therapeutic UICC stage on the basis of evaluating the pretherapeutic T and N categories. Results of EUS should be discussed on the background of neoadjuvant therapy including response evaluation and in comparison with the results of magnetic resonance imaging. In addition, there is only little information available concerning evaluation of the circumferential resection margin by EUS. Technical improvements, such as the 3D-EUS, might be appropriate in the future to provide enhancement of EUS staging of rectal tumors.

Anatomically accurate hard priors for transrectal electrical impedance tomography (TREIT) of the prostate

Current prostate biopsy procedures entail sampling tissues at template-based locations that are not patient specific. Ultrasound (US)-coupled transrectal electrical impedance tomography (TREIT), featuring an endorectal US probe retrofitted with electrodes, has been developed for prostate imaging. This multi-modal imaging system aims to identify suspicious tumor regions based on their electrical properties and ultimately provide additional patient-specific locations where to take biopsy samples. Unfortunately, the open-domain geometry associated with TREIT results in a severely ill-posed problem due to the small number of measurements and unbounded imaging domain. Furthermore, reconstructing contrasts within the prostate volume is challenging because the conductivity differences between the prostate and surrounding tissues are much larger than the conductivity differences between benign and malignant tissues within the prostate. To help overcome these problems, anatomically accurate hard priors can be employed to limit estimation of the electrical property distribution to within the prostate volume; however, this requires the availability of structural information. Here, a method that extracts the prostate surface from US images and incorporates this surface into the image reconstruction algorithm has been developed to enable estimation of electrical parameters within the prostate volume. In this paper, the performance of this algorithm is evaluated against a more traditional EIT algorithm that does not use anatomically accurate structural information, in the context of numerical simulations and phantom experiments. The developed anatomically accurate hard-prior algorithm demonstrably identifies contrasts within the prostate volume while an algorithm that does not rely on anatomically accurate structural information is unable to localize these contrasts. While inclusions are identified in the correct locations, they are found to be smaller in size than the actual object due to the rapid decay in sensitivity at increasing distances from the probe surface. Despite this, identifying the size of the inclusion accurately may not be essential for biopsy guidance in a clinical setting; instead, knowledge of the general vicinity of a cancerous lesion may be sufficient for suggesting and guiding clinicians to extract additional biopsy cores.

Imaging in lower urinary tract infections

In epididymo-orchitis, a sonogram shows a non-homogenous and hypertrophied epididymis and testis, with increased vascularisation seen on a Doppler sonogram. Abscesses must be investigated using sonography so that a necrotic tumour is not misdiagnosed. In prostatitis, sonography is indicated to investigate urine retention and where treatment has failed (to look for a blockage, an abscess, or pyelonephritis). Endorectal sonography is the best imaging modality for analysing the parenchyma, but otherwise has limited value. Chronic prostatitis is the main differential diagnosis from prostate cancer; the two may be distinguished using diffusion MRI. In cases of cystitis, imaging is indicated when a patient has recurrent cystitis (to investigate what the causative factors might be), or an infection with a less common bacterium (to look for calcifications, emphysema, any involvement of the upper urinary tract), and in cases of cystitis with pseudotumour.

Neoadjuvant Treatment Response As an Early Response Indicator for Patients With Rectal Cancer

Neoadjuvant chemoradiotherapy for rectal cancer is associated with improved local control and may result in complete tumor response. Associations between tumor response and disease control following radical resection should be established before tumor response is used to evaluate treatment strategies. The purpose of this study was to assess and compare oncologic outcomes associated with the degree of pathologic response after chemoradiotherapy. All patients with locally advanced (cT3-4 or cN+ by endorectal ultrasonography, computed tomography, or magnetic resonance imaging) rectal carcinoma diagnosed from 1993 to 2008 at our institution and treated with preoperative chemoradiotherapy and radical resection were identified, and their records were retrospectively reviewed. The median radiation dose was 50.4 Gy with concurrent chemotherapy. Recurrence-free survival (RFS), distant metastasis (DM), and local recurrence (LR) rates were compared among patients with complete (ypT0N0), intermediate (ypT1-2N0), or poor (ypT3-4 or N+) response by using Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression. In all, 725 patients were classified by tumor response: complete (131; 18.1%), intermediate (210; 29.0%), and poor (384; 53.0%). Age, sex, cN stage, and tumor location were not related to tumor response. Tumor response (complete v intermediate v poor) was associated with 5-year RFS (90.5% v 78.7% v 58.5%; P < .001), 5-year DM rates (7.0% v 10.1% v 26.5%; P < .001), and 5-year LR only rates (0% v 1.4% v 4.4%; P = .002). Treatment response to neoadjuvant chemoradiotherapy among patients with locally advanced rectal cancer undergoing radical resection is an early surrogate marker and correlate to oncologic outcomes. These data provide guidance with response-stratified oncologic benchmarks for comparisons of novel treatment strategies.

Cáncer de recto: diagnóstico, estudio y estadificación

Rectal cancer: diagnosis, study and staging Rectal cancer is defi ned as a tumour located between the anal verge and 15 cm within anal verge. In rectal cancer, a precise preoperative staging allows to categorize patients for different available treatments, as well as decide the best surgical treatment. Preoperative staging is performed by several radiological tech- niques. Currently available procedures are endorectal ultrasound (EUS), computed tomography (CT) mag- netic resonance (MRI), positron emission tomography-computed tomography (PET/CT) and intraoperative ultrasound. EUS is a procedure performed by the colorrectal surgeon that allows the evaluation of the depth of tumour invasion as well as lymph node status; nevertheless its main shortcoming is the inability to assess mesorectal fascia involvement. Nowadays, MRI is the best method to assess mesorectal fascia involvement in addition to tumour invasion and lymph nodes involved. CT is a widely available procedure, and its main use is evaluation of distant metastases, with lower accuracy to assess tumour invasion and lymph node status. PET/CT is currently gaining importance, however its role in preoperative staging it's not widely accepted. IOUS allows evaluation of liver metastases during surgery, and therefore determines management and prog- nosis. Consequently, is necessary for surgeons to maintain an up-to-date knowledge of current methods, its advantages and limitations.

Improvement in T-Staging of Rectal Carcinoma: Using a Novel Endorectal Ultrasonography Technique with Sterile Coupling Gel Filling the Rectum

Our purpose was to study the accuracy of using endorectal ultrasonography (ERUS) with sterile coupling gels filling the rectum in the preoperative T-staging of rectal carcinoma. A total of 189 patients with confirmed rectal carcinoma were recruited. All underwent ERUS and surgery within the week following sonography. EURS was performed by introducing sterile coupling gel into the rectum. Two radiologists looked at the images at the same time and agreed upon staging. Rectal carcinoma was staged from Tis to T4. The accuracy of T-staging by ERUS was 89.95%. The sensitivity, specificity, PPV and NPV for ERUS at different stages were calculated. For early stage (Tis and T1), these values were 93.62%, 97.89%, 93.62% and 97.89%, respectively. ERUS filling with sterile coupling gel in the rectum overcomes the pressure effect from a water bath and the restriction caused by tumor stenosis, thus, greatly improving the accuracy of T-staging. The examination is real-time, safe and inexpensive.

Accuracy of Endorectal Ultrasound for Measurement of the Closest Predicted Radial Mesorectal Margin for Rectal Cancer

At present, pelvic phased array-coil MR is used as the validated imaging modality for measurement of the closest predicted radial mesorectal margin for rectal cancer. Endorectal ultrasound is also used to assess the clinical stage of the cancer that will determine the recommendation for neoadjuvant chemoradiation, but it has not been used to assess the closest predicted radial margin. We propose to assess endorectal ultrasound identification of mesorectal margins and the measurement of the closest predicted radial tumor-mesorectal margin. Patients included were those having MRI and endorectal ultrasound for evaluation of primary rectal cancer in 2010 at a tertiary cancer referral colorectal clinic. Clinical data, MRI, and endorectal ultrasound images were assessed. Two independent retrospective measurements of mesorectal dimensions were correlated to evaluate the reproducibility of identifying mesorectal margins. MRI and endorectal ultrasound images were compared for independent measurements of mesorectal dimensions and of the closest predicted radial mesorectal margin. MRI and endorectal ultrasound determination of margin involvement were assessed for agreement. Fifty-two patients were studied with an average rectal cancer distance to the anal verge of 6.8 cm. Interobserver correlation coefficients of endorectal ultrasound mesorectal dimensions ranged from 0.47 to 0.53 (p < 0.01). MR and endorectal ultrasound measurements of the closest predicted radial mesorectal margin were correlated r = 0.56 (p < 0.0001). MR and endorectal ultrasound determination of margin involvement agreed in 81% of cases. Endorectal ultrasound has substantial agreement with MR to measure the closest predicted radial tumor-mesorectal margin. Correlations between observers and modalities for identification of mesorectal dimensions are modest. Further assessment is indicated to confirm endorectal ultrasound mesorectal measurements in a larger sample and to understand the advantages and disadvantages relative to MR.

Preoperative staging of rectal cancer: Role of 3D endorectal ultrasonography

Endorectal ultrasonography has become important part of preoperative staging of rectal cancer, providing adequate information for clinical decision-making in many cases. However, with the currently available ultrasonographic equipment and techniques, a good deal of relevant information may remain hidden. The advent of high-resolution three-dimensional endoluminal ultrasound, constructed from a synthesis of standard two-dimensional cross-sectional images, and of "Volume Render Mode," a technique to analyze information inside a three-dimensional volume, promises to improve the accuracy of rectal cancer staging. The anatomic structures in the pelvis, the axial and longitudinal extension of the tumor, the presence of slight or massive submucosal invasion in early rectal cancer may be imaged in greater detail. This additional information will bring an improvement for both planning and conduct of surgical procedures.

Assessment of haemorrhoidal artery network using colour duplex imaging and clinical implications

BackgroundDearterialization should reduce arterial overflow to haemorrhoids. The purpose of this study was to assess the topography of haemorrhoidal arteries.MethodsFifty patients with haemorrhoidal disease were studied. Using endorectal ultrasonography, six sectors were identified within the lower rectal circumference. Starting from the highest level (6 cm above the anorectal junction), the same procedure was repeated every 1 cm until the lowest level was reached (1 cm above the anorectal junction). Colour duplex imaging examinations identified haemorrhoidal arteries related to the rectal wall layers, and the arterial depth was calculated.ResultsHaemorrhoidal arteries were detected in 64·3, 66·0, 66·0, 98·3, 99·3 and 99·7 per cent of the sectors 6, 5, 4, 3, 2 and 1 cm above the anorectal junction respectively (P < 0·001). Most of the haemorrhoidal arteries were external to the rectal wall at 6 and 5 cm (97·9 and 90·9 per cent), intramuscular at 4 cm (55·0 per cent), and within the submucosa at 3, 2 and 1 cm above the anorectal junction (67·1, 96·6 and 100 per cent) (P < 0·001). The mean arterial depth decreased significantly from 8·3 mm at 6 cm to 1·9 mm at 1 cm above the anorectal junction (P < 0·001).ConclusionThis study demonstrated that the vast majority of haemorrhoidal arteries lie within the rectal submucosa at the lowest 2 cm above the anorectal junction. This should therefore be the best site for performing haemorrhoidal dearterialization.

Endorectal elastography in the evaluation of rectal tumours

Real-time elastography visualizes tissue compliance using an ultrasound platform. Elastography has been used, particularly in the breast, to characterize indeterminate lesions on B-mode imaging as either benign or malignant. The primary aim of this study was to assess the feasibility of routine endorectal elastography to evaluate rectal neoplasia. The secondary aim was to correlate elastography data with histopathological end-points. Sixty-nine patients referred to the outpatient clinic of the Department of Colorectal Surgery at Haukeland University Hospital for the evaluation of rectal tumours were included in this prospective cohort study. All patients underwent digital rectal examination, rigid rectoscopy with biopsy, endorectal ultrasonography and endorectal elastography. In each case a strain ratio was calculated, comparing the tumour tissue with adjacent reference tissue that appeared normal on ultrasound scanning. Histopathologically there were 23 adenomas and 45 adenocarcinomas. One patient died before surgical treatment. Adequate elastography images were obtained in 66/69 (96%) patients. Optimal discrimination of malignant and benign lesions was obtained using a strain ratio cut-off value of 1.25 (sensitivity, 0.93; specificity, 0.96; and accuracy, 0.94). Endorectal elastography can be performed as an integral part of the clinical evaluation of rectal tumours and has good patient compliance. The method is a promising modality for the discrimination between adenocarcinoma and adenoma of the rectum.

EUS-FNA assessment of extramesenteric lymph node status in primary rectal cancer

Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer. The accuracy of imaging alone with CT, magnetic resonance imaging, or rigid endorectal US is poor. The addition of EUS-FNA may enhance extramesenteric lymph node metastases detection (M1 disease) and overall staging accuracy. To evaluate the frequency of extramesenteric lymph node visualization by EUS and the rate of extramesenteric lymph node metastases by FNA. Secondary goals were to evaluate the clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases, disease progression, and overall mortality. Retrospective cohort study. Tertiary referral center. Forty-one of 316 patients (13%) with primary rectal cancer over a 6-year period had M1 disease by EUS-FNA. Significant clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases included the serum carcinoembryonic antigen level, tumor length 4 cm and longer, annularity 50% or more, sessile morphology, and lymph node size. The sensitivity and specificity of CT for extramesenteric lymph node metastases were 44% and 89%, respectively. Twenty-three of 316 rectal cancer endosonographic procedures (7.3%) were up-staged by FNA, which established extramesenteric lymph node metastases. Over a 4-year follow-up, disease progression and overall mortality of patients with extramesenteric lymph node metastases was observed in 6 patients (14.6%) and 14 patients (34%), respectively. Preoperative EUS-FNA identification of extramesenteric lymph node metastases outside of standard radiation fields or total mesorectal excision resection margins could affect medical and surgical planning.

Does a learning curve exist in endorectal two-dimensional ultrasound accuracy?

Aim of the study was to assess adequacy of Colorectal Surgical Society of Australia and New Zealand (CSSANZ) endorectal ultrasound (ERUS) training and whether a subsequent learning curve exists. A prospective audit of ERUS for staging rectal cancer by a single surgeon from commencement of consultant practice was performed. Data were recorded in a prospectively maintained database. The audit commenced on completion of CSSANZ training. T- and N-stage were assessed clinically, then by ERUS prior to treatment and finally by histology over 8 years. The results were compared over three time periods: the first a single year, then two three-year periods. Two hundred and seventy-two patients were examined. Two hundred and thirty-three were assessable for T-stage (13 no tumour excision, 26 long course pre-operative radiotherapy) and 142 for N-stage (74 endoanal excision, 17 proximal mesorectum un-assessable). Overall accuracy was 82% for T-stage and 73% for N-stage. Accuracy for T- and N-staging did not change significantly over the three time periods (T: 82.1, 82.3, 81.6%, P = 0.14; N: 83.3, 67.9, 74.2%, P = 0.31). The utility of ERUS was demonstrated by clinical assessment not being possible in 32% of cases and where the two modalities disagreed was correct 82% of the time. Endorectal ultrasound rectal cancer staging is accurate for T-stage. Competency in ERUS can be achieved in the CSSANZ fellowship and accuracy does not improve with further experience. An ERUS accreditation scheme should be established for future trainees.

Local Recurrence after Intended Curative Excision of Presacral Lesions: Causes and Preventions

This study was designed to explore causes for local recurrence of presacral lesions after intended curative surgery and discuss prevention strategies. Medical data of presacral lesions in our hospital from January 2001 to September 2009 were retrospectively studied, including preoperative examinations, intraoperative findings, and postoperative histopathologies. Of 39 patients (29 women and 10 men) with presacral lesions, who ranged in age from 14 to 71 (mean, 39.56) years, 7 patients were diagnosed with recurrent presacral lesions on admission. Preoperative pelvic MRI, pelvic CT, and endorectal ultrasonography (ERUS) were performed in 23, 22, and 8 cases, respectively. MRI/CT showed that five cases had two coexisting lesions and three cases had lobulated or dumbbell shaped lesions, all of which were confirmed by intraoperative findings. ERUS suspected involvement of the rectal wall in three cases: adhesion to the rectal wall in two cases, and tumor invasion in the remaining case. During the operation, 26, 8, and 2 cases were resected by the transsacral, transabdominal, and combined abdominosacral approach, respectively. Four patients underwent simultaneous coccygectomy, and three patients received simultaneous resection of the sacrum and coccyx. Simultaneous partial resection of the invaded sigmoid colon or rectum was performed in two patients, respectively. By postoperative pathological examination, three cases were found to have ruptured cystic lesions, three had previous cyst rupture history, and five had infected lesions. Presacral lesions are likely to be multiple, lobulated, infected, ruptured, and adhesive to the sacrococcyx and rectum, which contribute to the high local recurrence rate. Preoperative CT/MRI/ERUS and careful intraoperative exploration are required to direct surgical treatment and to reduce local recurrence. Optimal selection of surgical approach also is very important to reduce local recurrence. Presacral lesions attached to the sacrococcyx or rectum require simultaneous partial resection of the sacrococcyx or rectum to reduce local recurrence.

Accuracy of endorectal ultrasonography in evaluation of response to chemoradiation in locally advanced rectal cancer.

3543 Background: The aim of our retrospective study was to evaluate the accuracy of endorectal ultrasonography (ERUS) in case of neoadjuvant chemoradiation in locally advanced rectal cancer and to ...

Linear array ultrasonography to stage rectal neoplasias suitable for local treatment

Background Because of the many therapeutic options available, a reliable staging is crucial for rectal neoplasia management. Adenomas and cancers limited to the submucosa without lymph node involvement may be treated locally. Aims The aim of this study is to evaluate the diagnostic accuracy of endorectal ultrasonography in the staging of neoplasias suitable for local treatment. Methods We considered all patients who underwent endorectal ultrasonography between 2001 and 2010. The study population consisted of 92 patients with 92 neoplasias (68 adenocarcinomas and 24 adenomas). A 5 and 7.5 MHz linear array echoendoscope was used. The postoperative histopathologic result was compared with the preoperative staging defined by endorectal ultrasonography. Adenomas and cancers limited to the submucosa were considered together (pT0–1). Results The sensitivity, specificity, overall accuracy rate, positive predictive value, and negative predictive value of endorectal ultrasonography for pT0–1 were 86%, 95.6%, 91.3%, 94.9% and 88.7%. Those for nodal involvement were 45.4%, 95.5%, 83%, 76.9% and 84%, with 3 false positive results and 12 false negative. For combined pT0–1 and pN0, endorectal ultrasonography showed an 87.5% sensitivity, 95.9% specificity, 92% overall accuracy rate, 94.9% positive predictive value and 90.2% negative predictive value. Conclusion Endorectal linear array ultrasonography is a reliable tool to detect rectal neoplasias suitable for local treatment.

Determining the Need for Radical Surgery in Patients With T1 Rectal Cancer

In the era of modern preoperative staging of patients with rectal cancer, lymph node metastases can be reliably predicted by the histological features of the tumor and preoperative imaging. Local resection can then be safely offered to the patients who are at low risk of having malignant lymph nodes. We reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1N0 or T2N0 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients. Tertiary care referral center. Patients with preoperative imaging suggestive of T1N0 or T2N0 rectal cancer. To evaluate different clinical and pathologic tumor features as predictors of positive lymph nodes in T1 and T2 rectal cancers with negative radiographic nodes. Local resection of T1 and T2 rectal cancer results in lower morbidity compared with radical resection. However, recurrence rates after local resection are higher, likely owing to unresected nodal metastasis. Reports on predictors of lymph node metastasis remain inconsistent in the literature. Although local resection may be appropriate for some rectal cancers, selection criteria remain unclear. Despite indications of negative nodes on radiographic examination, 4 of 35 patients with T1 disease (11%) and 13 of 47 with T2 disease (28%) had positive nodes. On univariate analysis, the only significant predictor was depth of invasion: 24 of 65 patients with negative nodes (37%) vs 13 of 17 patients with positive nodes (76%) had tumors invading the lower third of the submucosa and beyond (P = .02). On logistic regression analysis accounting for depth of invasion (lower third of the submucosa and beyond), size, distance from anal verge, differentiation, and lymphovascular and small-vessel invasion, only depth of invasion remained a significant predictor. In all, 89% of patients with T1 disease (31 of 35) and 72% of those with T2 disease (34 of 47) underwent unnecessary radical resection. Endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography, for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. Thus, local resection for T2 rectal cancer is not justified. Local resection should be offered only to patients with superficial T1 tumors who will adhere to aggressive postoperative surveillance.

VHM09 The Use of Rectal EUS in the Management of Perianal and Fistulizing Crohn's Disease

BackgroundPerianal Crohn's represents an aggressive form of disease characterized by poor quality of life and increased risk of operative intervention. Many approaches have been used over the years in the evaluation and management of these patients. This includes EUA (exam under anesthesia), MRI, and CT scanning. Rectal endoscopic ultrasound (EUS) is now an accepted and effective modality for evaluation of complex perianal disease. It allows a minimally invasive, safe means of not only identifying perianal involvement, but aids in the ongoing evaluation of patients with indwelling setons or drains. This case series illustrates how EUS is being used in conjunction with surgical and other imaging modalities to enhance the care of these patients.Endoscopic methodsThis case series illustrates the use of radial rectal endosonography in the evaluation and management of patients with perianal and fistulizing Crohn's disease.Clinical implicationsThis case series shows the effectiveness of rectal endoscopic ultrasonography in the evaluation and management of patients with fistulizing Crohn's disease. Rectal EUS provides an alternative to CT scan and MRI and is less costly and invasive than exam under anesthesia (EUA) for patients requiring serial evaluations of their disease. EUS can allow physicians to make informed decisions about the need for operative interventions and can assess healing in those patients with setons or indwelling drains. BackgroundPerianal Crohn's represents an aggressive form of disease characterized by poor quality of life and increased risk of operative intervention. Many approaches have been used over the years in the evaluation and management of these patients. This includes EUA (exam under anesthesia), MRI, and CT scanning. Rectal endoscopic ultrasound (EUS) is now an accepted and effective modality for evaluation of complex perianal disease. It allows a minimally invasive, safe means of not only identifying perianal involvement, but aids in the ongoing evaluation of patients with indwelling setons or drains. This case series illustrates how EUS is being used in conjunction with surgical and other imaging modalities to enhance the care of these patients. Perianal Crohn's represents an aggressive form of disease characterized by poor quality of life and increased risk of operative intervention. Many approaches have been used over the years in the evaluation and management of these patients. This includes EUA (exam under anesthesia), MRI, and CT scanning. Rectal endoscopic ultrasound (EUS) is now an accepted and effective modality for evaluation of complex perianal disease. It allows a minimally invasive, safe means of not only identifying perianal involvement, but aids in the ongoing evaluation of patients with indwelling setons or drains. This case series illustrates how EUS is being used in conjunction with surgical and other imaging modalities to enhance the care of these patients. Endoscopic methodsThis case series illustrates the use of radial rectal endosonography in the evaluation and management of patients with perianal and fistulizing Crohn's disease. This case series illustrates the use of radial rectal endosonography in the evaluation and management of patients with perianal and fistulizing Crohn's disease. Clinical implicationsThis case series shows the effectiveness of rectal endoscopic ultrasonography in the evaluation and management of patients with fistulizing Crohn's disease. Rectal EUS provides an alternative to CT scan and MRI and is less costly and invasive than exam under anesthesia (EUA) for patients requiring serial evaluations of their disease. EUS can allow physicians to make informed decisions about the need for operative interventions and can assess healing in those patients with setons or indwelling drains. This case series shows the effectiveness of rectal endoscopic ultrasonography in the evaluation and management of patients with fistulizing Crohn's disease. Rectal EUS provides an alternative to CT scan and MRI and is less costly and invasive than exam under anesthesia (EUA) for patients requiring serial evaluations of their disease. EUS can allow physicians to make informed decisions about the need for operative interventions and can assess healing in those patients with setons or indwelling drains.

Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer

Preoperative chemoradiation is becoming the standard treatment for patients with locally advanced rectal cancer. However, since the introduction of total mesorectal excision (TME), local recurrence rates have been reduced significantly, and some patients can be spared from potentially toxic over treatment. The current study was designed to assess the factors that predict recurrence in an institutional series of patients with rectal cancer who had clinical T2 lymph node-positive (cT2N+) tumors or cT3N0/N+ tumors and underwent radical surgery without receiving preoperative chemoradiation. Between November 1997 and November 2008, the authors' multidisciplinary group preoperatively staged 398 patients with rectal cancer by using endorectal ultrasonography and/or magnetic resonance imaging. The analysis included 152 consecutive patients with cT2N+, cT3N0, or cT3N+ rectal cancer who underwent TME without receiving preoperative chemoradiation. Macroscopic assessment of the mesorectal excision and circumferential resection margins were determined. Factors potentially related to local recurrence (LR), disease-free survival (DFS) and cancer-specific survival (CSS) were analyzed. After a median follow-up of 39 months, the 5-year actuarial LR, DFS, and CSS rates were 9.5%, 65.4%, and 77.8%, respectively, for the whole group. Threatened mesorectal fascia at preoperative staging was the only independent preoperative factor that predicted a higher risk for LR (P = .007), shorter DFS (P = .007), and shorter CSS (P = .05). In particular, the 5-year LR rates for patients with and without preoperative threatened circumferential resection margins were 19.4% and 5.4%, respectively. The current results suggested that patients with rectal cancer clinically staged as T3N0/N+ or T2N+ with a free margin >2 mm from mesorectal fascia may undergo TME alone, avoiding over treatment with preoperative chemoradiation.