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102
Technical
Recurrent Extraluminal Rectal Carcinoma: Biopsy Under Sonographic Guidance Michael
Bachmann
Nielsen,1
Jan
Fog Pedersen,1
Jesper
Rectal endosonography is a reliable method for preoperative staging of rectal carcinoma [1]. The clinical value of this technique is perhaps even greater in postoperative management because some recurrences cannot be detected either by digital rectal examination or by rectoscopy [2-6]. Furthermore, with endosonography, biopsy can be performed under sonographic guidance. We report our preliminary experience with rectal endosonography and transrectal endosonographically guided biopsy of suspected recurrent lesions in five patients who had undergone prior resection of the rectum for carcinoma.
Subjects
and Methods
From January 1990 to February 1991 postoperative graphic examinations of patients with rectal carcinoma ,
endosono-
suggested
an
extraluminal recurrence in five of 1 0 examined patients, all of whom had undergone low anterior resection of the rectum for carcinoma.
Pathologic
staging of the five cases according to Duke’s classification in Table 1 . Because of the endosonographic findings, the five patients, all male, had sonographically guided transrectal biopsy. Rectal endosonography was performed with the patient in the left lateral position. A Br#{252}el & Kjr (Nrum, Denmark) sonographic scanner type 1846 with a 7-MHz rotating endoprobe type 1850 (sector, 360#{176}; focus, 2-5 cm) was used. The biopsy specimens were obtained transrectally by using a BrUel & Kjror 7-MHz multiplanar endoprobe type 8551 (sector, 1 12#{176}; focus, 1-6 cm). We used fine needles (0.8 or 1 .0 mm in diameter) for aspiration biopsies in all patients; in three patients, we also performed core-needle biopsies with Surecut (TSK, Tokyo, Japan) or Biopty-gun (Bard Ltd., Sunder[7]
is listed
Hald,2
and
2
Department Department
Transrectal
Christiansen2
land, England) devices with 1 .2-mm needles. IV antibiotics (gentamicm and metronidazole) were given immediately before the biopsy procedure.
One patient
required
general
May 1992 0361-803x/92/1
585-1025
© American
Roentgen
because
of pain.
The clinical, sonographic, and biopsy data are provided in Table 1 . Like the primary rectal tumors, the detected lesions were all hypoechoic, but they showed no other specific sonographic characteristics. In one patient, the mucosa appeared slightly injected on rectoscopy; in the remaining patients, the mucosa was normal. In one patient, a stenosis had developed at the site of the anastomosis, and dilation had been performed several times; in this patient, the lesion detected on endosonography was near the stenosis. In three patients, a recurrence was confirmed by the results of endosonographically guided biopsy (Fig. 1). In the remaining two patients, examination of the biopsy specimen showed no malignancy, and repeated endosonographic examinations showed no increase in the size of the lesion over the next 91 0 months (Fig. 2). We found no characteristics of the postoperative changes that distinguished them from recurrent lesions. We observed no complications, and the biopsy procedure was tolerated well in four patients; one patient needed general anesthesia because of pain.
Discussion Rectal endosonography erative management of
offers patients
27, 1991 ; accepted after revision November 13, 1991. of Radiology and Ultrasound, Glostrup Hospital, University of Copenhagen, DK-2600 Glostrup, Denmark. Address of Gastroenterologic Surgery D, Glostrup Hospital, University of Copenhagen, DK-2600 Glostrup, Denmark.
AJR 158:1025-1027,
anesthesia
Results
Received September 1
John
Note
Ray Society
an opportunity with rectal
reprint
requests
for postopcancer who
to M. B. Nielsen.
1026
Downloaded from www.ajronline.org by 50.32.199.250 on 10/23/15 from IP address 50.32.199.250. Copyright ARRS. For personal use only; all rights reserved
TABLE
NIELSEN
1: Results
Case
Age
No.
(yr)
of Endosonographically
Primary
Time Since
Duke’s Classification
Surgery (months)
1
47
C
18
2
75
C
3
Guided
ET AL.
4
5
39 57
48
C
3
A
3.5 24
B
Biopsy Rectoscopic Findings Injected
mucosa
Normal
Endosonographic Findings
AB
=
a spiration
biopsy,
CB
=
Normal Stenosis, mucosa
normal
Inflammation
10
AB CB
Inflammation Tumor cells
-
wall wall
Extraluminal
mass
AB
Normal
mass
AB
Normal
16
Normal
Extraluminal rounded
toward
NA
-
AB
Extraluminal
part of rectal wall and extending
Result
cells
Lesion unchanged
mass
con-
CB
Normal
AB CB
Tumor cells Inflammation
NA
9
Lesion unchanged
-
NA
masses
Ic. See Henrichsen
Fig. 1.-Recurrent extraluminal rectal carcinoma. A, Case 1: Transverse rectal endosonogram (seen from below, up is anterior)
involving
Months
After Biopsy
Extraluminal
Stenosis, normal mucosa
not applicab
Result Tumor
26
=
Type AB
Thickened Thickened
-
core biop sy, NA
1992
Follow-up
4 x 4 cm extraluminal mass
fluent Note.-
May
Biopsy
rounded
3
AJR:158,
and Christia
nsen [7] for expl anation
shows 4 x 4 cm extraluminal
of Duke’s
recurrence
(arrows)
classifications.
at site of resection
sacrum.
B, Case 3: Transverse rectal endosonogram shows thickening of rectal wall (up to 1 cm) anterioriy (arrow). Hypoechoic areas posteriorly (at 5 o’clock to 9 o’clock) are artifacts due to air in rectum. SV = seminal vesicles. C, Case 5: Transverse rectal endosonogram obtained with multiplane sector scanner shows a 4 x 2.5 cm conglomerate of rounded confluent hypoechoic masses (black arrows) appearing like enlarged lymph nodes. Note normal rectal wall (white arrow).
undergo sphincter-preserving resection. It may be possible with routine endosonographic follow-up to detect even small local recurrences at an early stage and thus improve the chances of curative surgery. Luminal recurrences are usually diagnosed on the basis of rectoscopic findings and biopsies performed before patients have endosonography. In these patients, endosonography can be used to detect local tumor extension or involvement of adjacent organs, findings that would affect additional treatment. Extraluminal recurrences will not be recognized at rectoscopy unless the bowel surface is involved, whereas with endosonography such recurrences can be visualized, as shown in this report.
In some patients nonmalignant postoperative changes may develop that sonographically resemble recurrent disease. Therefore, biopsy of any suspected lesion should be considered. In cases in which biopsies show nonmalignant cells, another biopsy should be considered or follow-up endosonography should be performed after several months to determine if the lesion has increased in size, suggesting tumor growth [2]. A lesion that does not increase in size may represent benign postoperative change. Some biopsies in our study suggested nonmalignant postoperative changes, which were confirmed by the subsequent clinical course. Sonographically guided transrectal biopsy of the prostate has been performed for several years, and complications are
Downloaded from www.ajronline.org by 50.32.199.250 on 10/23/15 from IP address 50.32.199.250. Copyright ARRS. For personal use only; all rights reserved
AJR:158,
May
1992
RECURRENT
EXTRALUMINAL
RECTAL
CARCINOMA
1027
Fig. 2.-Nonmalignant postoperative changes. A, Case 2: Transverse sonogram shows 1- to 1.5-cm hypoechoic extraluminal rounded mass (solid arrows) close to adjacent bowel wall (open arrows). B, Case 4: Magnification of transverse sonogram of rectal wall shows 0.5-cm-thick hypoechoic area (arrows) in rectal wall deep to submucoca (5).
usually few and minor. Only a few reports [2-6, 8] have described guided biopsies of recurrent rectal cancers or reCurrent pelvic masses. In some of these series, either the transperineal biopsy route was used or the biopsy procedures are not fully described [2-4]. Most endoprobes are designed for imaging of the prostate and lower rectum, so transrectal biopsies are usually confined to this part of the rectum. However, general anesthesia will provide maximal relaxation of the anal sphincter, and the endoprobe and biopsy needle then can be maneuvered to the middle or even upper part of the rectum. (This was not necessary for visualization of the recurrences in this series.) When biopsy specimens are taken from extraluminal masses, the bowel wall will be perforated, and with biopsies in the middle and upper part of the rectum, even the peritoneum may be perforated. We therefore give IV antibiotics immediately before the biopsy procedure. We found few descriptions of the needle types used in other reports; however, Tru-Cut or Biopty-gun devices have been used [4-6]. Only one report [8] describes the use of fine-needle aspiration biopsy. We initially thought that fineneedle aspiration biopsy would provide sufficient material for cytologic studies because demonstration of tumor cells would be diagnostic. However, in one patient, an additional core biopsy was necessary to provide enough material for histologic studies. We therefore now do both fine-needle aspiration biopsies for cytologic studies (three samples) and core biopsies for histologic studies (three samples). For the latter biopsies, we use a Biopty-gun device with a 1 .2-mm biopsy needle. Determination of the optimal biopsy approach awaits further study.
In summary, rectal endosonography may be useful in the postoperative management of patients with rectal carcinoma, particularly for the detection of extraluminal recurrent disease. Biopsy of any detected lesions should be considered because nonmalignant postoperative changes may resemble recurrence. Biopsy can be performed transrectally under sonographic guidance. We recommend performing both fineneedle aspiration and core biopsies in such cases. In addition, postoperative follow-up of these patients should include imaging for widespread metastatic disease. REFERENCES 1 . Romano G, Dc Rosa Intrarectal ultrasound operative assessment
1985;72[suppll:S1
P. Vallone G, Rotondo A, Grassi A, Santangelo ML. and computed tomography in the pre -and postof patients with rectal carcinoma. Br J Surg
17-119
2. Beynon J, Mortensen NJM, Foy DMA, Channer JL, Rigby H, Virjee J. The detection and evaluation of locally recurrent rectal cancer with rectal endosonography. Dis Colon Rectum 1989;32:509-517 3. Hildebrandt U, Feifel G, Schwarz HP, Scherr 0. Endorectal ultrasound: instrumentation and clinical aspects. mt J ColorectalDis 1986:1:203-207 4. Zainea GC, Lee F, McLeary AD, Siders DB, Thieme ET. Transrectal ultrasonography in the evaluation of rectal and extrarectal disease. Surg Gynecol Obst 1989;169:153-156 5. Andersson A, Aus G. Transrectal ultrasound-guided biopsy for verification of lymph-node metastasis in rectal canoer. Case report. Acta Chir Scand 1990;156:659-660 6. Mascagni D, Corbelli L, Urciuoli, Di Matteo G. Endoluminal ultrasound for early detection of local recurrence of rectal cancer. Br J Surg 1989;76: 1176-1180 7. Henrichsen S, Christiansen J. Prognostic staging of extraperitoneal rectal cancer. Dis Colon Rectum 1989;32:214-218 8. Mandell MJ, Thieme GA, Eggli KD, Ballantine TVN. Transrectal ultrasound guided needle biopsy of recurrent vaginal mass in a 23 month old girl. Pediatr Radiol 1989;20: 120-1 21
102
Technical
Recurrent Extraluminal Rectal Carcinoma: Biopsy Under Sonographic Guidance Michael
Bachmann
Nielsen,1
Jan
Fog Pedersen,1
Jesper
Rectal endosonography is a reliable method for preoperative staging of rectal carcinoma [1]. The clinical value of this technique is perhaps even greater in postoperative management because some recurrences cannot be detected either by digital rectal examination or by rectoscopy [2-6]. Furthermore, with endosonography, biopsy can be performed under sonographic guidance. We report our preliminary experience with rectal endosonography and transrectal endosonographically guided biopsy of suspected recurrent lesions in five patients who had undergone prior resection of the rectum for carcinoma.
Subjects
and Methods
From January 1990 to February 1991 postoperative graphic examinations of patients with rectal carcinoma ,
endosono-
suggested
an
extraluminal recurrence in five of 1 0 examined patients, all of whom had undergone low anterior resection of the rectum for carcinoma.
Pathologic
staging of the five cases according to Duke’s classification in Table 1 . Because of the endosonographic findings, the five patients, all male, had sonographically guided transrectal biopsy. Rectal endosonography was performed with the patient in the left lateral position. A Br#{252}el & Kjr (Nrum, Denmark) sonographic scanner type 1846 with a 7-MHz rotating endoprobe type 1850 (sector, 360#{176}; focus, 2-5 cm) was used. The biopsy specimens were obtained transrectally by using a BrUel & Kjror 7-MHz multiplanar endoprobe type 8551 (sector, 1 12#{176}; focus, 1-6 cm). We used fine needles (0.8 or 1 .0 mm in diameter) for aspiration biopsies in all patients; in three patients, we also performed core-needle biopsies with Surecut (TSK, Tokyo, Japan) or Biopty-gun (Bard Ltd., Sunder[7]
is listed
Hald,2
and
2
Department Department
Transrectal
Christiansen2
land, England) devices with 1 .2-mm needles. IV antibiotics (gentamicm and metronidazole) were given immediately before the biopsy procedure.
One patient
required
general
May 1992 0361-803x/92/1
585-1025
© American
Roentgen
because
of pain.
The clinical, sonographic, and biopsy data are provided in Table 1 . Like the primary rectal tumors, the detected lesions were all hypoechoic, but they showed no other specific sonographic characteristics. In one patient, the mucosa appeared slightly injected on rectoscopy; in the remaining patients, the mucosa was normal. In one patient, a stenosis had developed at the site of the anastomosis, and dilation had been performed several times; in this patient, the lesion detected on endosonography was near the stenosis. In three patients, a recurrence was confirmed by the results of endosonographically guided biopsy (Fig. 1). In the remaining two patients, examination of the biopsy specimen showed no malignancy, and repeated endosonographic examinations showed no increase in the size of the lesion over the next 91 0 months (Fig. 2). We found no characteristics of the postoperative changes that distinguished them from recurrent lesions. We observed no complications, and the biopsy procedure was tolerated well in four patients; one patient needed general anesthesia because of pain.
Discussion Rectal endosonography erative management of
offers patients
27, 1991 ; accepted after revision November 13, 1991. of Radiology and Ultrasound, Glostrup Hospital, University of Copenhagen, DK-2600 Glostrup, Denmark. Address of Gastroenterologic Surgery D, Glostrup Hospital, University of Copenhagen, DK-2600 Glostrup, Denmark.
AJR 158:1025-1027,
anesthesia
Results
Received September 1
John
Note
Ray Society
an opportunity with rectal
reprint
requests
for postopcancer who
to M. B. Nielsen.
1026
Downloaded from www.ajronline.org by 50.32.199.250 on 10/23/15 from IP address 50.32.199.250. Copyright ARRS. For personal use only; all rights reserved
TABLE
NIELSEN
1: Results
Case
Age
No.
(yr)
of Endosonographically
Primary
Time Since
Duke’s Classification
Surgery (months)
1
47
C
18
2
75
C
3
Guided
ET AL.
4
5
39 57
48
C
3
A
3.5 24
B
Biopsy Rectoscopic Findings Injected
mucosa
Normal
Endosonographic Findings
AB
=
a spiration
biopsy,
CB
=
Normal Stenosis, mucosa
normal
Inflammation
10
AB CB
Inflammation Tumor cells
-
wall wall
Extraluminal
mass
AB
Normal
mass
AB
Normal
16
Normal
Extraluminal rounded
toward
NA
-
AB
Extraluminal
part of rectal wall and extending
Result
cells
Lesion unchanged
mass
con-
CB
Normal
AB CB
Tumor cells Inflammation
NA
9
Lesion unchanged
-
NA
masses
Ic. See Henrichsen
Fig. 1.-Recurrent extraluminal rectal carcinoma. A, Case 1: Transverse rectal endosonogram (seen from below, up is anterior)
involving
Months
After Biopsy
Extraluminal
Stenosis, normal mucosa
not applicab
Result Tumor
26
=
Type AB
Thickened Thickened
-
core biop sy, NA
1992
Follow-up
4 x 4 cm extraluminal mass
fluent Note.-
May
Biopsy
rounded
3
AJR:158,
and Christia
nsen [7] for expl anation
shows 4 x 4 cm extraluminal
of Duke’s
recurrence
(arrows)
classifications.
at site of resection
sacrum.
B, Case 3: Transverse rectal endosonogram shows thickening of rectal wall (up to 1 cm) anterioriy (arrow). Hypoechoic areas posteriorly (at 5 o’clock to 9 o’clock) are artifacts due to air in rectum. SV = seminal vesicles. C, Case 5: Transverse rectal endosonogram obtained with multiplane sector scanner shows a 4 x 2.5 cm conglomerate of rounded confluent hypoechoic masses (black arrows) appearing like enlarged lymph nodes. Note normal rectal wall (white arrow).
undergo sphincter-preserving resection. It may be possible with routine endosonographic follow-up to detect even small local recurrences at an early stage and thus improve the chances of curative surgery. Luminal recurrences are usually diagnosed on the basis of rectoscopic findings and biopsies performed before patients have endosonography. In these patients, endosonography can be used to detect local tumor extension or involvement of adjacent organs, findings that would affect additional treatment. Extraluminal recurrences will not be recognized at rectoscopy unless the bowel surface is involved, whereas with endosonography such recurrences can be visualized, as shown in this report.
In some patients nonmalignant postoperative changes may develop that sonographically resemble recurrent disease. Therefore, biopsy of any suspected lesion should be considered. In cases in which biopsies show nonmalignant cells, another biopsy should be considered or follow-up endosonography should be performed after several months to determine if the lesion has increased in size, suggesting tumor growth [2]. A lesion that does not increase in size may represent benign postoperative change. Some biopsies in our study suggested nonmalignant postoperative changes, which were confirmed by the subsequent clinical course. Sonographically guided transrectal biopsy of the prostate has been performed for several years, and complications are
Downloaded from www.ajronline.org by 50.32.199.250 on 10/23/15 from IP address 50.32.199.250. Copyright ARRS. For personal use only; all rights reserved
AJR:158,
May
1992
RECURRENT
EXTRALUMINAL
RECTAL
CARCINOMA
1027
Fig. 2.-Nonmalignant postoperative changes. A, Case 2: Transverse sonogram shows 1- to 1.5-cm hypoechoic extraluminal rounded mass (solid arrows) close to adjacent bowel wall (open arrows). B, Case 4: Magnification of transverse sonogram of rectal wall shows 0.5-cm-thick hypoechoic area (arrows) in rectal wall deep to submucoca (5).
usually few and minor. Only a few reports [2-6, 8] have described guided biopsies of recurrent rectal cancers or reCurrent pelvic masses. In some of these series, either the transperineal biopsy route was used or the biopsy procedures are not fully described [2-4]. Most endoprobes are designed for imaging of the prostate and lower rectum, so transrectal biopsies are usually confined to this part of the rectum. However, general anesthesia will provide maximal relaxation of the anal sphincter, and the endoprobe and biopsy needle then can be maneuvered to the middle or even upper part of the rectum. (This was not necessary for visualization of the recurrences in this series.) When biopsy specimens are taken from extraluminal masses, the bowel wall will be perforated, and with biopsies in the middle and upper part of the rectum, even the peritoneum may be perforated. We therefore give IV antibiotics immediately before the biopsy procedure. We found few descriptions of the needle types used in other reports; however, Tru-Cut or Biopty-gun devices have been used [4-6]. Only one report [8] describes the use of fine-needle aspiration biopsy. We initially thought that fineneedle aspiration biopsy would provide sufficient material for cytologic studies because demonstration of tumor cells would be diagnostic. However, in one patient, an additional core biopsy was necessary to provide enough material for histologic studies. We therefore now do both fine-needle aspiration biopsies for cytologic studies (three samples) and core biopsies for histologic studies (three samples). For the latter biopsies, we use a Biopty-gun device with a 1 .2-mm biopsy needle. Determination of the optimal biopsy approach awaits further study.
In summary, rectal endosonography may be useful in the postoperative management of patients with rectal carcinoma, particularly for the detection of extraluminal recurrent disease. Biopsy of any detected lesions should be considered because nonmalignant postoperative changes may resemble recurrence. Biopsy can be performed transrectally under sonographic guidance. We recommend performing both fineneedle aspiration and core biopsies in such cases. In addition, postoperative follow-up of these patients should include imaging for widespread metastatic disease. REFERENCES 1 . Romano G, Dc Rosa Intrarectal ultrasound operative assessment
1985;72[suppll:S1
P. Vallone G, Rotondo A, Grassi A, Santangelo ML. and computed tomography in the pre -and postof patients with rectal carcinoma. Br J Surg
17-119
2. Beynon J, Mortensen NJM, Foy DMA, Channer JL, Rigby H, Virjee J. The detection and evaluation of locally recurrent rectal cancer with rectal endosonography. Dis Colon Rectum 1989;32:509-517 3. Hildebrandt U, Feifel G, Schwarz HP, Scherr 0. Endorectal ultrasound: instrumentation and clinical aspects. mt J ColorectalDis 1986:1:203-207 4. Zainea GC, Lee F, McLeary AD, Siders DB, Thieme ET. Transrectal ultrasonography in the evaluation of rectal and extrarectal disease. Surg Gynecol Obst 1989;169:153-156 5. Andersson A, Aus G. Transrectal ultrasound-guided biopsy for verification of lymph-node metastasis in rectal canoer. Case report. Acta Chir Scand 1990;156:659-660 6. Mascagni D, Corbelli L, Urciuoli, Di Matteo G. Endoluminal ultrasound for early detection of local recurrence of rectal cancer. Br J Surg 1989;76: 1176-1180 7. Henrichsen S, Christiansen J. Prognostic staging of extraperitoneal rectal cancer. Dis Colon Rectum 1989;32:214-218 8. Mandell MJ, Thieme GA, Eggli KD, Ballantine TVN. Transrectal ultrasound guided needle biopsy of recurrent vaginal mass in a 23 month old girl. Pediatr Radiol 1989;20: 120-1 21
