Biomed & Pharmacorher ( 1992)46,133- 138 0 Elsevier, Paris
133
~n~oscop~c ~~~rasonograp~y in colorectal diseases G
Roseau,
L Palazzo, JA Paolaggi
Hapitol Cochin 27, rue du Foubourg St-Jacques, 75014 Paris, France
(Received 26 March 1992; accepted 2 April 1992)
Summary - Since new flexible high-frequency ultrasound endoscopas are now available, the use of this technique in colorectal disease has been determined. Its role in the preoperative staging of rectal cancer, and in follow-up after surgery has been es~biished, but its use in cases of anal cancer and in bold-neo~lastic rectal diseases still has to be demonstrated more precisely. endoscopic uitrasan~rapby I rectum t colon R&sum&- L’Ccho-endoscopie en pathologic recto.colique. Avec l’a:+wment des nouveaux &ho-endoscopes souples de haute frkquence, les indications en pathologic anale et recta-colique se sont prkise’es. L’inte’r~t de I’Pcho-endoscopie dons le cancer du rectum est ir p&sent dkmontr6 par de nombreuses &udes pal. I le staging pr&op&atoire. et le suivi aprk tvuitement chirurgical, Z’inftSt dans les cancers de [‘anus et en parhologie ilrnctofogique est encore en tours d’haluation. &ho-endoscopie I rectum I colon
Endosonography of the rectum in determining cancer staging has been performed for several years, mainly with biind rigjd instruments. More recently, the use of flexible ultrasound endoscopes has been proposed, allowing endosonography throngbout the colon, collection of biopsies and use of high frequencies, both in determining cancer staging and in assessing benign diseases.
Technique and end~sonog~aphi~ semiology Most of the instruments available for endorectal sonography are still rigid echorectoscopes. These non-flexible probes are introduced blindly into the rectum through a rigid proctoscope. Depending on the type of instrument, they can provide radical images perpendicular to the axit; of the endoscope, or linear images. With the latter probes, longitudinal sections are obtained and the instrument has to be rotated to investigate the entire
circumferential extent of the lesion. Anal and colorectal investigation can also be performed with the oblique viewing er,doscope usually used for the upper gastrointestinal tract, emitting frequencies of 7.5 MHz and 12 MHz, or with a new 7.5 MHz ultrasound forward-viewing colonoscope. In order to establish a necessary tiuid interface between the transducer and the color& wall, a balloon placed over the transducer has to be filled with fluid, or the segment of the bowel to be studied filled with water. These examinations should always be pe~ormed after administration of an enema, and after standard rectosigmoidoscopic examination to first establish the localisation and orientation of the region of interest. The use of intravenous analgesia and sedation may be necessary to pass through the rectosigmoid junction in some cases. Patients are usually studied in lithotomy or left lateral position. The probe is inserted and advanced to the area under study which is scanned by slowly moving the ins~ument. In the case of rectal cancer, the
134 transducer should always be positioned in the sigmoid to investigate the presence of metastatic lymph nodes of the iliac axis. Normal rectal and colonic wall appears as a 5-layer pattern [1, 5, 201. The innermost hyperechoic layer and the second hypoechoic layer correspond to the border echo (balloon with water and mucosa), and to the mucosa respectively. The third (hyperechoic) layer corresponds to the border echo between the mucosa and submucosal surface and the submucosal layer. The fourth (hypoechoic) layer corresponds to the muscularis propria, and the fifth to the border echo between the muscularis propria and the serosa or perirectal fat layer. In some cases, using a 12 MHz frequency, 7 layers can be seen because of an additional interface between the inner circular and the other longitudinal areas of the muscularis propria. Using the 7.5MHz frequency, the penetration depth of an ultrasound scan is about 4 cm. Investigation of surrounding organs and structures therefore is possible. From the colon, part of the liver, pancreas, spleen and both kidneys can be visuaiized. In the sigmoid position, the iliac axis can be seen, Rnd from the rectum both urinary bladder and prostate and seminal vesicles or uterus car be visualized.
and should always be performed before planning therapy. In the case of advanced carcinoma with lymph node metastases or invading perirectal fat, it will lead to radiotherapy before surgery in order to decrease the risk of local recurrence, or to adjuvant treatment with radio- and chemotherapy. In the case of a low rectal parietal lesion, endoscopic ultrasonography will help to determine whether local excision or abdominoperineal amputation should be performed [2]. The typical appearance of rectal carcinoma at EUS is an echo-poor or non-homogeneous lesion with irregular borders. Using an echographic classification derived from
Fig 2. T2 rectal carcinoma 7.5 MHz.
Fig 1. Normal rectal wall with a 5 layer pattern.
ndoscopic ultrasonography cinoma
in rectal car-
Endoscopic ultrasonography gives good results in determining the staging of rectal adenocarcinoma,
Fig 3. T2 rectal carcinoma
12 MHz.
TNM, rectal carcinomas can be classified as follows: Tl (cancer limited to mucosae or submucosae; parietal thickening is limited by the third hyperechoic layer); T2 (cancer with involvement of muscularis propria: a loss of the third hyperechoic layer can be seen); T3 (perirectal fat or subserosal fat involvement appearing as a disruption of the outermost. hyperechoic layer); and T4 (involvement of an adjacent organ). Perirectai lymph nodes are supposed to be metastatic when they take the form of round hypoechoic lesions. Differentiation between ~r&~an~~ato~ and malignant nodes may be difficult p~i~ularly in the case of isoechoic or small nodes. According to the literature, once patients with unexaminable stenotic lesions have been excluded (S-30%) the diagnostic accuracy of endoscopic ultrasonography in the evaluation of parietal involvement by rectal carcinoma is 80-85% [3, 4, 7, 9-11, 17, 20, 25, 28, 29, 35-37, 401. Difficulty arises in the distinction between carcinomatous infiltration and inflammatory lesions because of their practically similar hypotenicity. Underestimation of T3 carcinoma with ~nicroscopic involvement of perirectal fat is another li~tation of endoscopic ultrasonography. Diagnostic accuracy for metastatic lymph nodes is only 50-75%, and the number of false positives and negatives is still high. The use of flexible endoscopes, that can be placed above the reciosigmoid junction, is very useful in investigating the presence of iliac axis lymph nodes. In studies with comparisons between endosonography and computed tomography, the superiority of
Fig 5. Villous adenomn.
Fig 5. ~ater~an~tomotic
Fig 4. Metastatic
lymph nodes.
recurrent carcinoma.
the former is clear, particularly for small parietal tumors and detection of lymph node metastasis [3, 12, 25, 281. Endoscopic ultrasonography has also been utilized in the post-operative assessment of anastomoses after resection of rectal carcinoma. Usually such recurrence is detected in 80% of cases wi&in 2 years of surgical treatment 118, 19, 23, 241. Their prognosis is bad, and their treatment difficult as most of them are situated outside the bowel lumen with late diagnosis [6, 38, 391. Barium enema, coloscopy and computed tomography have known limits in making such a diagnosis. !n 7 prospective studies, it has been proved that the diagnosis of recurrence could be made when
136 latero-anastomotic or rectocolic hypoechoic masses are observed [4, 16, 21, 26, 27, 30, 331. The invasion of the ottermost layers of the rectocolic wall (serosa and muscularis propria) is characteristic. The diagnosis of small lesions of 1 cm in diameter is possible, but it has not yet been proven that such an early diagnosis could lead to a better prognosis. Furthermore, difficulties arise in discriminating granulomas or fibrous tissues from residual or recurrent neoplastic diseases. This problem may be resolved by performing another sonogram after 6 weeks and deep biopsies in the event that the lesions have extended. According to Mascagni et al [21] an optimal follow-up after resection could consist of repetitive endoscopic ultrasonography every 3 months within 2 years of resection, and every 6 months thereafter. In the case of women with prior abdominal perineal amputation, this followup may be carried out by endovaginal echography. Using such a procedure, these aI:hors have diagnosed 40% of asymptomatic recurrence from endoscopic ultrasonography alone. Once diagnosed because of their potential malignancy, selecting a suitable treatment for rectosigmoid villous adenomas proves a difficult undertaking. Malignancy is present in 8-47% of cases, and very often underestimated on superficial biopsies. As in other studies using rigid probes, we have demonstrated that using a flexible endoscopic ultrasonography with both frequencies of 7.5 and 12 MHz and an operative channel for filling the rectum with water, the evaluation of depth penetration of proliferating le-
Fig 7. Radial rectum, unsharp thickening
pria.
of the muscularis
pro-
sions could be made with high precision [ 15, 311. This is of utmost importance when the lesion is large or situated high up, and cannot be clinically correctly examined. Although it is impossible to differentiate a benign villous adenoma from a malignant one with invasion limited to submucosae, a malignant (VA) villous adenoma with inmuscularis propria is easily vasion of distinguishable from other cases.
Future prospects for endoscopic ultrasonography. Role in anal carcinoma subepithelial tumors and non-neoplastic diseases As anal epidermoid carcinoma is a rare form of cancer very few studies have been published on the role of endoscopic ultrasonography in these lesions. Goldman et al [14] and Giovannini et al [ 131 have both demonstrated that it could be useful in the pre-treatment evaluation, mostly by showing previously undetected metastatic lymph nodes. Its role in monitoring the effects of radio- and chemotherapy, and in follow-up to demonstrate local recurrence, is also promising [13, 141. In our own series, we have also had similar results on the role of endoscopy before and after radiotherapy [32]. The use of endoscopic ultrasonography in benign diseases has not been covered as fully as it has been for rectal carcinoma. Nevertheless, in the upper gastrointestinal tract it has proved useful in the diagnosis of external compressions and subepitheiial tumors (leiomyomas, lipomas and endometriosis etc). It has also been reported in a few patients for diagnosis and measurement of perirectal accesses and fistulae, even in patients with Crohn’s disease [8, 221. Blind and endoscopic ultrasonography have already assumed a very important role in determining rectal cancer staging and in many other indications. Future developments may arise from a decrease in the diameter of ultrasound components, or development of probes that could pass through the operative channel of an endoscope. This could allow exploration of stenotic lesions. Development of echocoloscopy with histomorphometry to distinguish malignant from benign nodes, and the ability to make echography-guided biopsies should also lead to wider applications and better results.
137
References 1 Aibe study wall Stand
T, Fuji T, Okita K et al (1986) A fundamental of normal layer structure of gastrointestinal visualized by endoscopic ultrasonography. J Gastroenterol 21 (suppl, 123), 16
2 Anderberg B, Enblad P, Sjodahl R, Wetterfors J (1983) The EEA-stapling device in anterior resection for carcinoma of the rectum. Acta Ckir Scan 149, 99 3 Beynon J, McC Mortensen NJ, Foy DMA et al (1986) Pre-operative assessment of local invasion in rectal cancer: digital examination, endoluminal sonography or computed tomography? Br J Surg 73, 1015 4 Beynon J, McC Mortecsen NJ, Foy DMA et al (1989) The detection and evaluation of locally recurrent rectal cancer with rectal endosonography. Dis Colon Rectum 32, 509
5 Bolondi L, Caletti GC, Casanova P (1986) Problems and variations in the interpretation of the ultrasound feature of the normal upper and lower GI tract wall. Stand J Gastroenterol 21 (suppl 123), 16 6 Cochrane JPS, Williams JT, Faber RG, Slack WW (1980) Value of outpatient follow-up after curative surgery for carcinoma of the large bowel. Br Med J 3, 593 7 Di Candio G, Mosca F, Campatelli A et al (1987) Endosonographic staging of rectal carcinoma. Gastmintest Radio1 12, 289
8 Dolle A, Sim AJW (I987) Endoluminal in begnin anorectal disease (abstract). 1369
ultrasound Cur 28 A
9 Dormer A, Kahl HJ, Petersen P, Reich P (1988) Intrakavitare sonographie. Rontgenblatter 4 1, 186 10 Dragstedt J, Milton P, Jorgensen T et al (1988) Endoluminal rectal ultrasound-scanning of patients with rectal carcinoma. Endoscopy 20, 94 I1 Feifel G, Hildebrandt LI, Dohm G (1987) Assessment of depth of invasion in rectal cancer by endosonography. Endoscopy 19, 64 12 Feuerbach S, iukas P, Gmeinwieser J (1984) Fehlinterpretationen im Computertomogramm bei malignen Lymphknotenerkrankungem im Becken und Abdomen. Digitale Bilddiagn 4, 176 13 Giovannini M, Seitz JF, Rosello R (1990) Inter&t de i’echographie endo-ano-rectale dans le bilan d’extension et la surveillance des cancers du canal anal. Anrl Gastroenterol Hepatol 26(l),
3
14 Goldman S, Glimelius B, Norming U et al (1988) Transanorectal ultrasonography in anal carcinoma. A prospective study of El patients. Acta Radio1 29 (3): 337
15 Glaser F, Fried1 P, Von Ditfurth et nl (1990) influence of endorectal uitrasound on surgical treatment of rectal cancer. Eur J Surg Oncol 16(4), 304 16 Hildebrandt U, Feifel G, Schwarz HP, Scherr 0 (1986) Endorectal ultrasound: instrumentation and clinical aspects. Int .I Colon Dis 4, 203 17 Hildebrandt LI, Feifel G (1988) Endosonographie des Rektums: Indikationen und Konsequenzen. Endoskrynol Heute 13, 4
18 Hoio K (1986) Anastomotic recurrence after sphincter-saving resection for rectal cancer: length cf distal clearance of the bowel. Die Colon Rectu;;; 29, !I 19 Hurst PA, Prout WG, Kelly JM et al (1982) Local recurrence after low anterior resection using the staple gun. Br J Surg 69, 275-276 20 Konishi F, Muto T, Takahashi H er al (1985) Transrectal ultrasonography for the assessment of invasion of rectal carcinoma. Dis Colon Rectum 28, 889-894 21 Mascagni D, Corbellini L, Urceiuli P, Di Matte0 G (1989) Endoluminal ultrasound for early detection of iocal recurrence of rectal cancer. Br J Surg 76, 1176-1180 22 Mudler CJJ, Tio TL, Tytgat GNJ (1988) Transrectal ultrasonography in the assessment of perianorectal fistula and/or abscess in Crohn’s disease (abstract). Gastroenterology, 94, A 313 23 Philips RKS, Hittinger R, Blesovsky L, Fry JS, Fiedling LP (1984) Local recurrence following curative surgery for large bowel cancer. II. The rectum and rectosigmoid. Br J Surg, 71, 17-20 24 Reid JDS, Robins RE, Atkinson KG (1984) Pelvic recurrence after anterior resection and EEA stapling anastomosis for potentially curable carcinoma of the rectum. Am J Surg 147. 629-632 25 Rifkin MD, Ehrlich SM, Marks G (1988) -Staging of i8.?cklcarcinoma. Prospective comparison of endorectal US and CT. Radiology 170, 319-322 26 Rifkin HD, Marks GJ (1985) Transrectal US as an adjunct in the diagnosis of rectal and extrarectal tumors. Radiology 157, 459-502 27 Roman0 G, De Rosa P, Vallone G e.t al (1985) Intrarectal ultrasound and computed tomography in the pre and postoperative assessment of patients with rectal cancer. Br J Surg 70, 117 28 Roman0 G, De Rosa P, Vallone G et al (1985) Intrarectal ultrasound and computed tomography in the pre-and postoperative assessment of patients with rectal cancer. Br J Surg 72 (suppl), 117 29 Roseau G, Palazzo L, Amouyal P et al (1990) Echoendoscopie dans le bilan pre-operatoire des cancers du rectum (etude prospective chez 31 malades). Presse med. 19, 1450 30 Roseau G, Palazzo L, Rahme T et al (1991) APPort de l’echo-endoscopie au diagnostic des r6cidives loco-rCgionales aprks cure chirurgicale des cancers
13s
31
32
33
34
35
recta-coliques. Gasrroenterol Clin Biol. 15 (2 bis): A 66 Roseau G, Palazzo L, Rahme T er al ( 199 1) Inter&t de I’echo-endoscopie dans le bilan pre-thbrapeutique recta-sigmdidiennes. villeuses tumeurs des Gastroenterol Clin Biol 15 (2 bis): A 277 Roseau G, Palazzo L, Chaussade S (1992) Endoscopic ultrasonography in the staging and follow up of epidermoid carcinoma of the anal canal. Gastroenterology 102, A392 Rosch Th, Lorenz R, Classen M (1990) Colonic endosonography is superior to computed tomography and endoscopy in detecting postoperative recurrence in colorectal cancer. Gasrrointerst Endosc 36, A 152 Saitoh H, Okuy K, Sarashina H et al (1986) Evaluation of echographic diagnosis of rectal cancer using intrarectal ultrasonic examination. Dis Colon Rectum 29, 234 Salena BJ, Sivak MV, Lavery I, Petras R (1988) Endoscopic ultrasound in the pre-operative assessment
of anorectal malignancy: a preliminary stract). Gastrointest Endosc 34, 208
report (ab-
36 Strunk H, Frank K, Kuntz Ch ei ril (1988) Endorektale Sonographie beim Rektumkarzinom. ROFO 149, 420 37 Tio TI, Tytgat GNJ (1986) Comparison of blind transrectal ultrasonography with endoscopic transrectal ultrasonography in assessing rectal and perirectal diseases. Stand J Gastroenterol 21 (suppl 123), 104-111 38 Umpleby HC, Williamson RCN (1987) Anastomotic recurrence in large bowel cancer. Br J Surg 74, 873 39 Welch JP, Donaldson GA (1978) Detection and treatment of recurrent cancer of the colon and rectum. Am J Surg 135, 505 40 Yamashita Y, Machi J, Shirouzu K ef al (1988) Evaluation of endorectal ultrasound for the assessment of wall invasion of rectal cancer. Dis Colon Rectum 31, 617
133
~n~oscop~c ~~~rasonograp~y in colorectal diseases G
Roseau,
L Palazzo, JA Paolaggi
Hapitol Cochin 27, rue du Foubourg St-Jacques, 75014 Paris, France
(Received 26 March 1992; accepted 2 April 1992)
Summary - Since new flexible high-frequency ultrasound endoscopas are now available, the use of this technique in colorectal disease has been determined. Its role in the preoperative staging of rectal cancer, and in follow-up after surgery has been es~biished, but its use in cases of anal cancer and in bold-neo~lastic rectal diseases still has to be demonstrated more precisely. endoscopic uitrasan~rapby I rectum t colon R&sum&- L’Ccho-endoscopie en pathologic recto.colique. Avec l’a:+wment des nouveaux &ho-endoscopes souples de haute frkquence, les indications en pathologic anale et recta-colique se sont prkise’es. L’inte’r~t de I’Pcho-endoscopie dons le cancer du rectum est ir p&sent dkmontr6 par de nombreuses &udes pal. I le staging pr&op&atoire. et le suivi aprk tvuitement chirurgical, Z’inftSt dans les cancers de [‘anus et en parhologie ilrnctofogique est encore en tours d’haluation. &ho-endoscopie I rectum I colon
Endosonography of the rectum in determining cancer staging has been performed for several years, mainly with biind rigjd instruments. More recently, the use of flexible ultrasound endoscopes has been proposed, allowing endosonography throngbout the colon, collection of biopsies and use of high frequencies, both in determining cancer staging and in assessing benign diseases.
Technique and end~sonog~aphi~ semiology Most of the instruments available for endorectal sonography are still rigid echorectoscopes. These non-flexible probes are introduced blindly into the rectum through a rigid proctoscope. Depending on the type of instrument, they can provide radical images perpendicular to the axit; of the endoscope, or linear images. With the latter probes, longitudinal sections are obtained and the instrument has to be rotated to investigate the entire
circumferential extent of the lesion. Anal and colorectal investigation can also be performed with the oblique viewing er,doscope usually used for the upper gastrointestinal tract, emitting frequencies of 7.5 MHz and 12 MHz, or with a new 7.5 MHz ultrasound forward-viewing colonoscope. In order to establish a necessary tiuid interface between the transducer and the color& wall, a balloon placed over the transducer has to be filled with fluid, or the segment of the bowel to be studied filled with water. These examinations should always be pe~ormed after administration of an enema, and after standard rectosigmoidoscopic examination to first establish the localisation and orientation of the region of interest. The use of intravenous analgesia and sedation may be necessary to pass through the rectosigmoid junction in some cases. Patients are usually studied in lithotomy or left lateral position. The probe is inserted and advanced to the area under study which is scanned by slowly moving the ins~ument. In the case of rectal cancer, the
134 transducer should always be positioned in the sigmoid to investigate the presence of metastatic lymph nodes of the iliac axis. Normal rectal and colonic wall appears as a 5-layer pattern [1, 5, 201. The innermost hyperechoic layer and the second hypoechoic layer correspond to the border echo (balloon with water and mucosa), and to the mucosa respectively. The third (hyperechoic) layer corresponds to the border echo between the mucosa and submucosal surface and the submucosal layer. The fourth (hypoechoic) layer corresponds to the muscularis propria, and the fifth to the border echo between the muscularis propria and the serosa or perirectal fat layer. In some cases, using a 12 MHz frequency, 7 layers can be seen because of an additional interface between the inner circular and the other longitudinal areas of the muscularis propria. Using the 7.5MHz frequency, the penetration depth of an ultrasound scan is about 4 cm. Investigation of surrounding organs and structures therefore is possible. From the colon, part of the liver, pancreas, spleen and both kidneys can be visuaiized. In the sigmoid position, the iliac axis can be seen, Rnd from the rectum both urinary bladder and prostate and seminal vesicles or uterus car be visualized.
and should always be performed before planning therapy. In the case of advanced carcinoma with lymph node metastases or invading perirectal fat, it will lead to radiotherapy before surgery in order to decrease the risk of local recurrence, or to adjuvant treatment with radio- and chemotherapy. In the case of a low rectal parietal lesion, endoscopic ultrasonography will help to determine whether local excision or abdominoperineal amputation should be performed [2]. The typical appearance of rectal carcinoma at EUS is an echo-poor or non-homogeneous lesion with irregular borders. Using an echographic classification derived from
Fig 2. T2 rectal carcinoma 7.5 MHz.
Fig 1. Normal rectal wall with a 5 layer pattern.
ndoscopic ultrasonography cinoma
in rectal car-
Endoscopic ultrasonography gives good results in determining the staging of rectal adenocarcinoma,
Fig 3. T2 rectal carcinoma
12 MHz.
TNM, rectal carcinomas can be classified as follows: Tl (cancer limited to mucosae or submucosae; parietal thickening is limited by the third hyperechoic layer); T2 (cancer with involvement of muscularis propria: a loss of the third hyperechoic layer can be seen); T3 (perirectal fat or subserosal fat involvement appearing as a disruption of the outermost. hyperechoic layer); and T4 (involvement of an adjacent organ). Perirectai lymph nodes are supposed to be metastatic when they take the form of round hypoechoic lesions. Differentiation between ~r&~an~~ato~ and malignant nodes may be difficult p~i~ularly in the case of isoechoic or small nodes. According to the literature, once patients with unexaminable stenotic lesions have been excluded (S-30%) the diagnostic accuracy of endoscopic ultrasonography in the evaluation of parietal involvement by rectal carcinoma is 80-85% [3, 4, 7, 9-11, 17, 20, 25, 28, 29, 35-37, 401. Difficulty arises in the distinction between carcinomatous infiltration and inflammatory lesions because of their practically similar hypotenicity. Underestimation of T3 carcinoma with ~nicroscopic involvement of perirectal fat is another li~tation of endoscopic ultrasonography. Diagnostic accuracy for metastatic lymph nodes is only 50-75%, and the number of false positives and negatives is still high. The use of flexible endoscopes, that can be placed above the reciosigmoid junction, is very useful in investigating the presence of iliac axis lymph nodes. In studies with comparisons between endosonography and computed tomography, the superiority of
Fig 5. Villous adenomn.
Fig 5. ~ater~an~tomotic
Fig 4. Metastatic
lymph nodes.
recurrent carcinoma.
the former is clear, particularly for small parietal tumors and detection of lymph node metastasis [3, 12, 25, 281. Endoscopic ultrasonography has also been utilized in the post-operative assessment of anastomoses after resection of rectal carcinoma. Usually such recurrence is detected in 80% of cases wi&in 2 years of surgical treatment 118, 19, 23, 241. Their prognosis is bad, and their treatment difficult as most of them are situated outside the bowel lumen with late diagnosis [6, 38, 391. Barium enema, coloscopy and computed tomography have known limits in making such a diagnosis. !n 7 prospective studies, it has been proved that the diagnosis of recurrence could be made when
136 latero-anastomotic or rectocolic hypoechoic masses are observed [4, 16, 21, 26, 27, 30, 331. The invasion of the ottermost layers of the rectocolic wall (serosa and muscularis propria) is characteristic. The diagnosis of small lesions of 1 cm in diameter is possible, but it has not yet been proven that such an early diagnosis could lead to a better prognosis. Furthermore, difficulties arise in discriminating granulomas or fibrous tissues from residual or recurrent neoplastic diseases. This problem may be resolved by performing another sonogram after 6 weeks and deep biopsies in the event that the lesions have extended. According to Mascagni et al [21] an optimal follow-up after resection could consist of repetitive endoscopic ultrasonography every 3 months within 2 years of resection, and every 6 months thereafter. In the case of women with prior abdominal perineal amputation, this followup may be carried out by endovaginal echography. Using such a procedure, these aI:hors have diagnosed 40% of asymptomatic recurrence from endoscopic ultrasonography alone. Once diagnosed because of their potential malignancy, selecting a suitable treatment for rectosigmoid villous adenomas proves a difficult undertaking. Malignancy is present in 8-47% of cases, and very often underestimated on superficial biopsies. As in other studies using rigid probes, we have demonstrated that using a flexible endoscopic ultrasonography with both frequencies of 7.5 and 12 MHz and an operative channel for filling the rectum with water, the evaluation of depth penetration of proliferating le-
Fig 7. Radial rectum, unsharp thickening
pria.
of the muscularis
pro-
sions could be made with high precision [ 15, 311. This is of utmost importance when the lesion is large or situated high up, and cannot be clinically correctly examined. Although it is impossible to differentiate a benign villous adenoma from a malignant one with invasion limited to submucosae, a malignant (VA) villous adenoma with inmuscularis propria is easily vasion of distinguishable from other cases.
Future prospects for endoscopic ultrasonography. Role in anal carcinoma subepithelial tumors and non-neoplastic diseases As anal epidermoid carcinoma is a rare form of cancer very few studies have been published on the role of endoscopic ultrasonography in these lesions. Goldman et al [14] and Giovannini et al [ 131 have both demonstrated that it could be useful in the pre-treatment evaluation, mostly by showing previously undetected metastatic lymph nodes. Its role in monitoring the effects of radio- and chemotherapy, and in follow-up to demonstrate local recurrence, is also promising [13, 141. In our own series, we have also had similar results on the role of endoscopy before and after radiotherapy [32]. The use of endoscopic ultrasonography in benign diseases has not been covered as fully as it has been for rectal carcinoma. Nevertheless, in the upper gastrointestinal tract it has proved useful in the diagnosis of external compressions and subepitheiial tumors (leiomyomas, lipomas and endometriosis etc). It has also been reported in a few patients for diagnosis and measurement of perirectal accesses and fistulae, even in patients with Crohn’s disease [8, 221. Blind and endoscopic ultrasonography have already assumed a very important role in determining rectal cancer staging and in many other indications. Future developments may arise from a decrease in the diameter of ultrasound components, or development of probes that could pass through the operative channel of an endoscope. This could allow exploration of stenotic lesions. Development of echocoloscopy with histomorphometry to distinguish malignant from benign nodes, and the ability to make echography-guided biopsies should also lead to wider applications and better results.
137
References 1 Aibe study wall Stand
T, Fuji T, Okita K et al (1986) A fundamental of normal layer structure of gastrointestinal visualized by endoscopic ultrasonography. J Gastroenterol 21 (suppl, 123), 16
2 Anderberg B, Enblad P, Sjodahl R, Wetterfors J (1983) The EEA-stapling device in anterior resection for carcinoma of the rectum. Acta Ckir Scan 149, 99 3 Beynon J, McC Mortensen NJ, Foy DMA et al (1986) Pre-operative assessment of local invasion in rectal cancer: digital examination, endoluminal sonography or computed tomography? Br J Surg 73, 1015 4 Beynon J, McC Mortecsen NJ, Foy DMA et al (1989) The detection and evaluation of locally recurrent rectal cancer with rectal endosonography. Dis Colon Rectum 32, 509
5 Bolondi L, Caletti GC, Casanova P (1986) Problems and variations in the interpretation of the ultrasound feature of the normal upper and lower GI tract wall. Stand J Gastroenterol 21 (suppl 123), 16 6 Cochrane JPS, Williams JT, Faber RG, Slack WW (1980) Value of outpatient follow-up after curative surgery for carcinoma of the large bowel. Br Med J 3, 593 7 Di Candio G, Mosca F, Campatelli A et al (1987) Endosonographic staging of rectal carcinoma. Gastmintest Radio1 12, 289
8 Dolle A, Sim AJW (I987) Endoluminal in begnin anorectal disease (abstract). 1369
ultrasound Cur 28 A
9 Dormer A, Kahl HJ, Petersen P, Reich P (1988) Intrakavitare sonographie. Rontgenblatter 4 1, 186 10 Dragstedt J, Milton P, Jorgensen T et al (1988) Endoluminal rectal ultrasound-scanning of patients with rectal carcinoma. Endoscopy 20, 94 I1 Feifel G, Hildebrandt LI, Dohm G (1987) Assessment of depth of invasion in rectal cancer by endosonography. Endoscopy 19, 64 12 Feuerbach S, iukas P, Gmeinwieser J (1984) Fehlinterpretationen im Computertomogramm bei malignen Lymphknotenerkrankungem im Becken und Abdomen. Digitale Bilddiagn 4, 176 13 Giovannini M, Seitz JF, Rosello R (1990) Inter&t de i’echographie endo-ano-rectale dans le bilan d’extension et la surveillance des cancers du canal anal. Anrl Gastroenterol Hepatol 26(l),
3
14 Goldman S, Glimelius B, Norming U et al (1988) Transanorectal ultrasonography in anal carcinoma. A prospective study of El patients. Acta Radio1 29 (3): 337
15 Glaser F, Fried1 P, Von Ditfurth et nl (1990) influence of endorectal uitrasound on surgical treatment of rectal cancer. Eur J Surg Oncol 16(4), 304 16 Hildebrandt U, Feifel G, Schwarz HP, Scherr 0 (1986) Endorectal ultrasound: instrumentation and clinical aspects. Int .I Colon Dis 4, 203 17 Hildebrandt LI, Feifel G (1988) Endosonographie des Rektums: Indikationen und Konsequenzen. Endoskrynol Heute 13, 4
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