Surgical Endoscopy
Surg Endosc (1991) 5:89-91
© Springer-Verlag 1991
The role of transvaginal sonography as compared with endorectal sonography in the evaluation of rectal cancer: preliminary study Radu Badea 1, Gheorghe Badea 2, Doru Dejiea 2, and Emil Henegar 1 1Institute of Hygiene and Public Health and 2 Third Medical Clinic, University of Medicine and Pharmacy, Str. Croitorilor 19-21, 3400 Cluj-Napoca, Romania
Summary. W e carried out a preliminary study on the efficacy o f endovaginal sonography (EVS) in the evaluation of rectal cancer. The study included 12 w o m e n with endoscopically documented rectal cancer, 10 of which were treated surgically. W e found that EVS evidenced metastasized lymph nodes (7/9) and infiltration of the rectovaginal space more clearly; moreover, this technique can also be performed in cases of stenosing cancer. Endorectal sonography (ERS) evidenced infiltration of the rectal wall but was less accurate both in detecting metastasized l y m p h nodes (6/9) and for exploration o f the rectovaginal space. W e concluded that the two methods c o m plement one another and improve ultrasonographic staging of rectal cancer. Key words: Rectal cancer Endovaginal sonography
-
Ultrasonography
-
The prognosis of rectal cancer is closely related to the speed o f its detection. Exact preoperative staging enables the elaboration of an adequate therapeutic strategy: extirpation o f the tumour within the limits o f oncologic safety, preservation of the anal sphincter, removal of tissues and organs invaded by the tumour, and selection of cases lending themselves to preoperative radiation therapy [9]. Besides M a s o n ' s digital method, introduced in 1976, endorectal sonography (ERS) [2, 8, 12] and c o m p u t e d tom o g r a p h y [10, 13] can also provide useful information on the stage of rectal cancer development. Current studies indicate that ERS is the most efficient, non-invasive and inexpensive method. However, this technique is not errorfree, especially in the assessment o f infiltration o f the rectovaginal space in w o m e n [2].
Offprint requests to: R. Badea
Endovaginal sonography (EVS) has recently been introduced into medical practice, its major application lying in the fields of gynaecologic and obstetric pathology [4, 7, 15]. N o study to date has dealt with the value of EVS in preoperative staging o f rectal cancer. The aim of the present preliminary study was to investigate the utility of EVS in the diagnosis of this disease in w o m e n and to compare the information obtained with that provided by ERS.
Patients and methods The present study was carried out in a group of 12 women with documented rectal cancer, diagnosed by rectoscopy. A Bruel & Kjaer 3405 rectoscope equipped with a rotating mechanical transducer operating at a frequency of 5.5 MHz was used for endocavitary examinations. The examinations were performed in a standard manner: patients with a full urinary bladder were instructed to lie in the supine position. The first phase of the examination involved EVS, which was used to reveal evidence of the rectal cancer; the degree of extension into the rectal wall, neighbouring organs, and the rectovaginal space; and metastasized lymph nodes. The second phase involved ERS, whereby the transducer was introduced up to the endoscopically indicated tumoral zone. ERS was carried out to determine the degree of neoplastic extension in a horizontal plane (infiltration of the rectal wall in relation to the mucosal musculature, involvement of the organs in the small pelvis) and in a vertical one (the depth at which the tumour appears and disappears from the ERS viewpoint). We used the 1987 clinical TNM classification system as a reference for staging. The sonographic evaluation of the rectal wall was based on the elegant study of Boscaini and Montori [5].
Results ERS could be performed in ten patients. The other two cases (EVS - T4) exhibited a stenosing rectal cancer that excluded the introduction of the transducer. The parietal infiltration was staged as follows: T2, 4 cases; T3, 5 cases; and T4, one case. The involvement o f perirectal lymph nodes was detected by ERS in six patients. EVS could be carried out in all 12 patients. With regard to rectal infiltration, EVS visualized the tumour in all cases (Fig. 1) but could not precisely determine which layers
90
Fig. 1. Aspect of a 12-cm rectal tumour evidenced by EVS. VAG., Vagina; R, rectum (markers indicate the tumour) Fig. 2. Rectovaginal fistula (double arrowheads) and infiltration of the posterior vaginal wall (markers = 9 mm). VAGIN, Vagina; RECT, rectum Fig. 3. Infiltration of the posterior vaginal wall by a rectal tumour (TU). Perirectal lymph nodes (AD) can be seen Fig. 4. Perirectal lymph nodes evidenced by EVS (markers = 6 mm)
Table 1. Results of EVS and ERS as compared with intraoperative
findings Patient no.
EVS
ERS
Intraoperative
1
Tx No
T2 No
T2 No
2 3 4 5 6 7 8 9 10 11 12
Tx N1 Tx No Tx N1 Tx No Tx N1 Tx No Tx N1 Tx N1 T4 N1 T4 N1 T4 No
T2 N1 T2 N1 T2 N1 T3 No T3 No T3 No T3 N1 T3 N1 T4 N1 Stenosis Stenosis
T2 N1 T2 N1 T2 N1 T3 N1 T3 N1 T3 N1 T4 N1 T4 N1 T4 N1
all cases. Metastasized lymph nodes were detected in nine cases.
Discussion
ERS is a well-known method of preoperative staging [ 1 - 3 , 6]. Although there is a certain amount of confusion as to the precise identification of rectal layers by ERS [1, 11, 12], by superimposing the ultrasonographic image onto anatomic rectal sections, complex experimental studies [5, 6] have demonstrated that the ultrasonographic substrate as shown by ERS is the result o f interfaces existing between the anatomic layers. It has also been shown that ERS can accurately visualize the proper rectal musculature, which enables the differentiation of the T2 stage of rectal cancer
E9]. were affected. Extraluminal development (T4) was visualized in three patients, one o f w h o m presented a rectovaginal fistula (Fig. 2); the other two exhibited only vaginal invasion (Fig. 3). Perirectal lymph nodes were sonographically evidenced in seven cases (Fig. 4). The comparative results of ERS and EVS are presented in Table 1. Surgical intervention was performed in ten patients. The intraoperafive finding confirmed the tumoral stage found by ERS in
It is now accepted that a 5 - M H z endorectal transducer visualizes the proper musculature in 92.1% of patients and the cancer itself in 100% o f cases. The accuracy of ERS is high, ranging between 81% [2] and 94% [14]; thus, it is the most sensitive of the preoperative staging techniques, followed by computed t o m o g r a p h y (CT) [10, 13] and nuclear magnetic resonance (NMR) [4]. ERS cannot be carried out in cases of stenosing tumours, which hinder the passage of the transducer [2].
91 M o r e o v e r , w h e n used to investigate t u m o u r infiltration o f the r e c t o v a g i n a l layer, it m a y introduce f a l s e - p o s i t i v e or f a l s e - n e g a t i v e results [2] b e c a u s e o f the v e r y tight anat o m i c relationship b e t w e e n the two organs. E V S can easily visualize the r e c t o v a g i n a l space. A l though the current literature e m p h a s i z e s the i m p o r t a n c e o f E V S in g y n a e c o l o g y and obstetrics, e. g. e x p l o r a t i o n o f the ovaries in o b e s e w o m e n [7] and the early d e t e c t i o n o f extrauterine p r e g n a n c y [4] and o f dilated F a l l o p i a n tubes [ 15], its o n c o l o g i c i m p o r t a n c e cannot b e o v e r l o o k e d . D u r i n g E V S , the rectal t u m o u r is easily visualized. T h e v i s u a l i z a t i o n is even m o r e accurate if the p r o c e d u r e is p r e c e d e d b y a cleansing enema. U n d e r these conditions, an e c h o g r a p h i c w i n d o w is created that can e v i d e n c e the endorectal r e l i e f o f the tumour. E V S cannot distinguish the rectal layers or their n e o p l a s t i c infiltration, as the a m p u l l a o f the r e c t u m is a virtual cavity. O n the other hand, it enables the e x a m i n a t i o n o f stenosing cancers that are inaccessible to ERS. T h e contribution o f E V S to the p r e o p e r a t i v e staging o f rectal cancer m a y be represented b y (1) p r e c i s e e v i d e n c e o f the n e o p l a s t i c extension into the posterior v a g i n a l w a l l and o f the c o m p l i c a t i o n s d e v e l o p i n g at this level (fistulae) and (2) high accuracy in the detection o f perirectal l y m p h nodes, w h i c h are visible at a size of about 5 ram. B y p r o v i d i n g these advantages, E V S does not substitute for ERS; rather, the two techniques c o m p l e m e n t one another. The results o b t a i n e d in this p r e l i m i n a r y study suggest the utility o f c o m b i n i n g E R S and E V S e x a m i n a t i o n s in w o m e n for better staging o f rectal cancer.
References 1. Alzin HH, Kohlberger E, Schwaiger R, Alloussi S (1983) Valeur de l'echographie endorectale dans la chirurgie du rectum. Ann Radiol 26:334-336
2. Badea R, Badea G, Philippi W, Dejica D, Bologa S, Cazacu M (1988) Wert und Grenzen der endorektalen Sonographie in der pr~ioperativen Stadieneinteilung des Rektumskarzinoms. UltraschaI1 9:265-269 3. Beynon J, Foy DMA, Roe AM, Temple LN, McMortensen NJ (1986) Endoluminal ultrasound in the assessment of local invasion in rectal cancer. Br J Surg 73:4744-4770 4. Bonilla-Musoles F, Pardo G, Sampaio M, Pellicer A, Simon C, Strasser J (1989) Vaginale Endosonographie bei extrauteriner Graviditfit. Ultraschali 10:215-221 5. Boscaini M, Montori A (1986) Transrectal ultrasonography: interpretation of normal intestinal wall structure for the preoperative staging of rectal cancer. Scand J Gastroenterol 21:87 - 98 6. Dragsted J, Gammlgaard J (1983) Endoluminal ultrasonic scanning in the evolution of rectal cancer: preliminary report of 13 cases. Gastrointest Radiol 8:367-369 7. Guy RL, King E, Ayers AB (1988) The role of transvaginal ultrasound in the assessment of the female pelvis. Clin Radiol 39: 669-672 8. Hildebrandt U, Feifel G, Schwarz HP, Schen O (1986) Endorectal ultrasound: instrumentation and chnical aspects. Int J Colorect Dis 1: 203-207 9. Konishi F, Muto T, Takahashi H, Itoh K, Kanazawa K, Morioka Y (1985) Transrectal ultrasonography for the assessment of invasion of rectal carcinoma. Dis Colon Rectum 28: 889- 894 10. Kramann B, Hildebrandt U (1986) Computed tomography versus endosonography in the staging of rectal carcinoma: a comparative study. Int J Colorect Dis 1: 216 - 218 11. Prevost F, Puech JL, Chalabi F, Roos S, Song MY, Fourtanier G, Joffre F, Escat J (1988) L'echographie endorectale dans Ie bilon d' extension des cancers du rectum apropos de vingt cas operes. Ann Chir 9:652-655 12. Rifldn DM, Gerald MJ (1985) Transrectal US as an adjunct in the diagnosis of rectal and extrarectal tumors. Radiology ! 57: 499- 502 13. Rotte KH, Kluhs L, Kleinau H, Kriedmann E (1989) Computed tomography and endosonography in the preoperative staging of rectal carcinoma. Eur J Radiol 9: 187-190 14. Senagore A, Milson JW, Talbott TM, Muldoon JP, Mazier WP (1988) Intrarectal ultrasonography in the staging and management of rectal tumors. Am Surg 54:352-355 15. Tessler FN, Perrella RR, Fleischer AC, Grant EG (1989) Endovaginal sonographic diagnosis of dilated fallopian tubes. AJR 153: 523-525
Surg Endosc (1991) 5:89-91
© Springer-Verlag 1991
The role of transvaginal sonography as compared with endorectal sonography in the evaluation of rectal cancer: preliminary study Radu Badea 1, Gheorghe Badea 2, Doru Dejiea 2, and Emil Henegar 1 1Institute of Hygiene and Public Health and 2 Third Medical Clinic, University of Medicine and Pharmacy, Str. Croitorilor 19-21, 3400 Cluj-Napoca, Romania
Summary. W e carried out a preliminary study on the efficacy o f endovaginal sonography (EVS) in the evaluation of rectal cancer. The study included 12 w o m e n with endoscopically documented rectal cancer, 10 of which were treated surgically. W e found that EVS evidenced metastasized lymph nodes (7/9) and infiltration of the rectovaginal space more clearly; moreover, this technique can also be performed in cases of stenosing cancer. Endorectal sonography (ERS) evidenced infiltration of the rectal wall but was less accurate both in detecting metastasized l y m p h nodes (6/9) and for exploration o f the rectovaginal space. W e concluded that the two methods c o m plement one another and improve ultrasonographic staging of rectal cancer. Key words: Rectal cancer Endovaginal sonography
-
Ultrasonography
-
The prognosis of rectal cancer is closely related to the speed o f its detection. Exact preoperative staging enables the elaboration of an adequate therapeutic strategy: extirpation o f the tumour within the limits o f oncologic safety, preservation of the anal sphincter, removal of tissues and organs invaded by the tumour, and selection of cases lending themselves to preoperative radiation therapy [9]. Besides M a s o n ' s digital method, introduced in 1976, endorectal sonography (ERS) [2, 8, 12] and c o m p u t e d tom o g r a p h y [10, 13] can also provide useful information on the stage of rectal cancer development. Current studies indicate that ERS is the most efficient, non-invasive and inexpensive method. However, this technique is not errorfree, especially in the assessment o f infiltration o f the rectovaginal space in w o m e n [2].
Offprint requests to: R. Badea
Endovaginal sonography (EVS) has recently been introduced into medical practice, its major application lying in the fields of gynaecologic and obstetric pathology [4, 7, 15]. N o study to date has dealt with the value of EVS in preoperative staging o f rectal cancer. The aim of the present preliminary study was to investigate the utility of EVS in the diagnosis of this disease in w o m e n and to compare the information obtained with that provided by ERS.
Patients and methods The present study was carried out in a group of 12 women with documented rectal cancer, diagnosed by rectoscopy. A Bruel & Kjaer 3405 rectoscope equipped with a rotating mechanical transducer operating at a frequency of 5.5 MHz was used for endocavitary examinations. The examinations were performed in a standard manner: patients with a full urinary bladder were instructed to lie in the supine position. The first phase of the examination involved EVS, which was used to reveal evidence of the rectal cancer; the degree of extension into the rectal wall, neighbouring organs, and the rectovaginal space; and metastasized lymph nodes. The second phase involved ERS, whereby the transducer was introduced up to the endoscopically indicated tumoral zone. ERS was carried out to determine the degree of neoplastic extension in a horizontal plane (infiltration of the rectal wall in relation to the mucosal musculature, involvement of the organs in the small pelvis) and in a vertical one (the depth at which the tumour appears and disappears from the ERS viewpoint). We used the 1987 clinical TNM classification system as a reference for staging. The sonographic evaluation of the rectal wall was based on the elegant study of Boscaini and Montori [5].
Results ERS could be performed in ten patients. The other two cases (EVS - T4) exhibited a stenosing rectal cancer that excluded the introduction of the transducer. The parietal infiltration was staged as follows: T2, 4 cases; T3, 5 cases; and T4, one case. The involvement o f perirectal lymph nodes was detected by ERS in six patients. EVS could be carried out in all 12 patients. With regard to rectal infiltration, EVS visualized the tumour in all cases (Fig. 1) but could not precisely determine which layers
90
Fig. 1. Aspect of a 12-cm rectal tumour evidenced by EVS. VAG., Vagina; R, rectum (markers indicate the tumour) Fig. 2. Rectovaginal fistula (double arrowheads) and infiltration of the posterior vaginal wall (markers = 9 mm). VAGIN, Vagina; RECT, rectum Fig. 3. Infiltration of the posterior vaginal wall by a rectal tumour (TU). Perirectal lymph nodes (AD) can be seen Fig. 4. Perirectal lymph nodes evidenced by EVS (markers = 6 mm)
Table 1. Results of EVS and ERS as compared with intraoperative
findings Patient no.
EVS
ERS
Intraoperative
1
Tx No
T2 No
T2 No
2 3 4 5 6 7 8 9 10 11 12
Tx N1 Tx No Tx N1 Tx No Tx N1 Tx No Tx N1 Tx N1 T4 N1 T4 N1 T4 No
T2 N1 T2 N1 T2 N1 T3 No T3 No T3 No T3 N1 T3 N1 T4 N1 Stenosis Stenosis
T2 N1 T2 N1 T2 N1 T3 N1 T3 N1 T3 N1 T4 N1 T4 N1 T4 N1
all cases. Metastasized lymph nodes were detected in nine cases.
Discussion
ERS is a well-known method of preoperative staging [ 1 - 3 , 6]. Although there is a certain amount of confusion as to the precise identification of rectal layers by ERS [1, 11, 12], by superimposing the ultrasonographic image onto anatomic rectal sections, complex experimental studies [5, 6] have demonstrated that the ultrasonographic substrate as shown by ERS is the result o f interfaces existing between the anatomic layers. It has also been shown that ERS can accurately visualize the proper rectal musculature, which enables the differentiation of the T2 stage of rectal cancer
E9]. were affected. Extraluminal development (T4) was visualized in three patients, one o f w h o m presented a rectovaginal fistula (Fig. 2); the other two exhibited only vaginal invasion (Fig. 3). Perirectal lymph nodes were sonographically evidenced in seven cases (Fig. 4). The comparative results of ERS and EVS are presented in Table 1. Surgical intervention was performed in ten patients. The intraoperafive finding confirmed the tumoral stage found by ERS in
It is now accepted that a 5 - M H z endorectal transducer visualizes the proper musculature in 92.1% of patients and the cancer itself in 100% o f cases. The accuracy of ERS is high, ranging between 81% [2] and 94% [14]; thus, it is the most sensitive of the preoperative staging techniques, followed by computed t o m o g r a p h y (CT) [10, 13] and nuclear magnetic resonance (NMR) [4]. ERS cannot be carried out in cases of stenosing tumours, which hinder the passage of the transducer [2].
91 M o r e o v e r , w h e n used to investigate t u m o u r infiltration o f the r e c t o v a g i n a l layer, it m a y introduce f a l s e - p o s i t i v e or f a l s e - n e g a t i v e results [2] b e c a u s e o f the v e r y tight anat o m i c relationship b e t w e e n the two organs. E V S can easily visualize the r e c t o v a g i n a l space. A l though the current literature e m p h a s i z e s the i m p o r t a n c e o f E V S in g y n a e c o l o g y and obstetrics, e. g. e x p l o r a t i o n o f the ovaries in o b e s e w o m e n [7] and the early d e t e c t i o n o f extrauterine p r e g n a n c y [4] and o f dilated F a l l o p i a n tubes [ 15], its o n c o l o g i c i m p o r t a n c e cannot b e o v e r l o o k e d . D u r i n g E V S , the rectal t u m o u r is easily visualized. T h e v i s u a l i z a t i o n is even m o r e accurate if the p r o c e d u r e is p r e c e d e d b y a cleansing enema. U n d e r these conditions, an e c h o g r a p h i c w i n d o w is created that can e v i d e n c e the endorectal r e l i e f o f the tumour. E V S cannot distinguish the rectal layers or their n e o p l a s t i c infiltration, as the a m p u l l a o f the r e c t u m is a virtual cavity. O n the other hand, it enables the e x a m i n a t i o n o f stenosing cancers that are inaccessible to ERS. T h e contribution o f E V S to the p r e o p e r a t i v e staging o f rectal cancer m a y be represented b y (1) p r e c i s e e v i d e n c e o f the n e o p l a s t i c extension into the posterior v a g i n a l w a l l and o f the c o m p l i c a t i o n s d e v e l o p i n g at this level (fistulae) and (2) high accuracy in the detection o f perirectal l y m p h nodes, w h i c h are visible at a size of about 5 ram. B y p r o v i d i n g these advantages, E V S does not substitute for ERS; rather, the two techniques c o m p l e m e n t one another. The results o b t a i n e d in this p r e l i m i n a r y study suggest the utility o f c o m b i n i n g E R S and E V S e x a m i n a t i o n s in w o m e n for better staging o f rectal cancer.
References 1. Alzin HH, Kohlberger E, Schwaiger R, Alloussi S (1983) Valeur de l'echographie endorectale dans la chirurgie du rectum. Ann Radiol 26:334-336
2. Badea R, Badea G, Philippi W, Dejica D, Bologa S, Cazacu M (1988) Wert und Grenzen der endorektalen Sonographie in der pr~ioperativen Stadieneinteilung des Rektumskarzinoms. UltraschaI1 9:265-269 3. Beynon J, Foy DMA, Roe AM, Temple LN, McMortensen NJ (1986) Endoluminal ultrasound in the assessment of local invasion in rectal cancer. Br J Surg 73:4744-4770 4. Bonilla-Musoles F, Pardo G, Sampaio M, Pellicer A, Simon C, Strasser J (1989) Vaginale Endosonographie bei extrauteriner Graviditfit. Ultraschali 10:215-221 5. Boscaini M, Montori A (1986) Transrectal ultrasonography: interpretation of normal intestinal wall structure for the preoperative staging of rectal cancer. Scand J Gastroenterol 21:87 - 98 6. Dragsted J, Gammlgaard J (1983) Endoluminal ultrasonic scanning in the evolution of rectal cancer: preliminary report of 13 cases. Gastrointest Radiol 8:367-369 7. Guy RL, King E, Ayers AB (1988) The role of transvaginal ultrasound in the assessment of the female pelvis. Clin Radiol 39: 669-672 8. Hildebrandt U, Feifel G, Schwarz HP, Schen O (1986) Endorectal ultrasound: instrumentation and chnical aspects. Int J Colorect Dis 1: 203-207 9. Konishi F, Muto T, Takahashi H, Itoh K, Kanazawa K, Morioka Y (1985) Transrectal ultrasonography for the assessment of invasion of rectal carcinoma. Dis Colon Rectum 28: 889- 894 10. Kramann B, Hildebrandt U (1986) Computed tomography versus endosonography in the staging of rectal carcinoma: a comparative study. Int J Colorect Dis 1: 216 - 218 11. Prevost F, Puech JL, Chalabi F, Roos S, Song MY, Fourtanier G, Joffre F, Escat J (1988) L'echographie endorectale dans Ie bilon d' extension des cancers du rectum apropos de vingt cas operes. Ann Chir 9:652-655 12. Rifldn DM, Gerald MJ (1985) Transrectal US as an adjunct in the diagnosis of rectal and extrarectal tumors. Radiology ! 57: 499- 502 13. Rotte KH, Kluhs L, Kleinau H, Kriedmann E (1989) Computed tomography and endosonography in the preoperative staging of rectal carcinoma. Eur J Radiol 9: 187-190 14. Senagore A, Milson JW, Talbott TM, Muldoon JP, Mazier WP (1988) Intrarectal ultrasonography in the staging and management of rectal tumors. Am Surg 54:352-355 15. Tessler FN, Perrella RR, Fleischer AC, Grant EG (1989) Endovaginal sonographic diagnosis of dilated fallopian tubes. AJR 153: 523-525
