Rectal Carcinoma

Disclosure INTRODUCTION
Section 2 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

Background: Adenocarcinoma of the rectum is a ma#or cause of mortality and mor idity in North America and $estern %uro"e& Rectal cancers are' after colon cancers' the second most common (I carcinoma and have the est "ro!nosis& )he *-year survival rate is a""ro+imately *,-& Screenin! for and removin! adenomatous "oly"s may im"rove survival rates& Almost all rectal cancers are "rimary adenocarcinomas& Patho h!"iolog!: Adenocarcinoma of the rectum arises as an intramucosal e"ithelial lesion' usually in an adenomatous "oly" or !land& As cancers !ro$' they invade the muscularis mucosa and lym"hatic and vascular structures to involve re!ional lym"h nodes' ad#acent structures' and distant sites' es"ecially the liver& Several factors increase the ris. for rectal cancer' includin! the follo$in!/

0i!h-fat' lo$-fi er diet Patient older than *, years Personal history of colorectal adenoma or carcinoma 12-fold ris.3 4irst-de!ree relative $ith colorectal cancer 12-fold ris.3 4amilial "oly"osis coli' (ardner syndrome' and )urcot syndrome 1in $hich all "atients $ithout a colectomy develo" colorectal carcinoma3 5uvenile "oly"osis syndrome' Peut6-5e!hers syndrome' and Muir syndrome 1ris. increased sli!htly3 0ereditary non"oly"osis colorectal cancer 1as many as *,- of "atients are affected3 Inflammatory o$el disease o Ulcerative colitis 1ris. is 2,- after 7* y3 o Crohn disease 18- to 9,-fold ris.3

#re$uenc!:

In the US: Colorectal cancers are the second most common cause of cancer death in develo"ed countries and the most common (I cancer& In 7,,,' there $ere an estimated 92,'7,, ne$ cases of colorectal cancer of $hich 2:'8,, involved the rectum and 9;'*,, the rectosi!moid #unction&

)he hi!hest (I cancer rates are in the Northeast and North Central states' and the lo$est rates are in the southern and $estern states 1e+ce"t for the San 4rancisco Bay area and 0a$aii' $hich have the hi!hest incidence in the United States3& Incidence rates' for colorectal cancer as a $hole' declined si!nificantly durin! 9<<7-9<<: 1-7&9- "er year3& Research su!!ests that these declines may e ecause of increased screenin! and "oly" removal' "reventin! "ro!ression of "oly"s to invasive cancers& )he death rate also has declined sli!htly&

Internationall!: )he incidence of rectal cancer is hi!hest in the $esterni6ed countries of North America' northern %uro"e' Australia' and Ne$ =ealand& Intermediate rates are found in southern %uro"e and lo$ rates in Africa' Asia' and South America& Rectal cancer sho$s less international variation than colon cancer& >hile a :,-fold difference is found in colon cancer incidence et$een countries $ith the hi!hest and lo$est rates' only an 9;-fold difference is found in incidence for rectal cancer& 0i!h colon-to-rectal cancer ratios 12-8/93 "revail in the $esterni6ed countries of North America' northern %uro"e' Australia' and Ne$ =ealand& Ratios e?uallin! less than 9 are ty"ical in Asia and Africa&

%ortalit!&%or'idit!: Pro!nosis is related to the sta!e of the disease at dia!nosis and to initial treatment& Althou!h a tumor' node' metastases 1)NM3 international classification system and a sta!in! C) system have een develo"ed recently' the Du.es classification 1or one of its modifications3 remains in $ide use 1see )a le 93& Pro!nosis also is affected y the histolo!ic !rade of the tumor& )he com"lications of rectal cancer include o struction 1common3@ fistula formation to small o$el' ladder' or va!ina 1uncommon3@ and "erforation 1rare3& )a le 9& Modified Du.es Classification System and *-year Survival RateA Stage A B C De"cri tion Bimited to the o$el $all %+tension to "ericolic fat@ no nodes Re!ional lym"h node metastases ()!r Sur*i*al Rate+ , ;2 C, 2,

Distant metastases 1liver' lun!' one3

9,

AModified from =in.in 1Dis Colon Rectum' 9<;23 Race:

In the United States' rectal cancer incidence rates are hi!her in $hite males than in lac. males' ut the rates for $hite and lac. females are similar& Colon cancer incidence rates also are similar amon! $hite and lac. males and females& Ris. rates rise for "o"ulations mi!ratin! from lo$-ris. to hi!h-ris. areas' as demonstrated clearly in 5a"anese immi!rants in 0a$aii and the continental United States' $here rates amon! immi!rants have risen to a""ro+imate those of the native "o"ulation& )he 9;-fold difference in rectal cancer rates et$een the country $ith the hi!hest rate and the country $ith the lo$est rate is si!nificantly less than the :,-fold difference in colon cancer rates& )his may reflect dietary differences in fat and fi er inta.e in different countries& )hese differences diminish $hen a $estern-ty"e diet is ado"ted&

Se-: An increased incidence e+ists in males in $esterni6ed countries& )he maleto-female ratio may vary from ;/C-</*& .ge: Df "atients $ith rectal carcinoma' <,- are older than *, years& Dnly *- of "atients are youn!er than 8, years& .natom!: )he rectum lies anterior to the sacrum and coccy+ and is a""ro+imately 9* cm lon!& )he rectosi!moid #unction is located at the end of the si!moid mesocolon& Its u""er third is covered almost com"letely y "eritoneum& Belo$ this level' the "eritoneum is reflected anteriorly onto the "osterior surface of the uterus and va!ina in females and onto the "osterior surface of the ladder in males& )he "eritoneal recesses' the "ouch of Dou!las 1rectouterine3' and the rectovesical "ouch lie et$een these or!ans& )he lo$er half of the rectum is entirely e+tra"eritoneal& )he rectum ends #ust elo$ the level of the coccy+& It turns "osteriorly throu!h the "u orectal slin! of the levator ani muscles to ecome the anal canal& )he rectum is su""lied y the su"erior rectal ranch of the inferior mesenteric artery and from ranches of the internal iliac arteries& )he rectal lym"hatics drain su"eriorly into the su"erior rectal' then the inferior mesenteric nodes' and laterally into the internal iliac nodes& )he rectal $all com"rises * layers' includin! the 193 mucosa 1lined $ith columnar e"ithelium3' 173 muscularis mucosa' 123 su mucosa' 183 muscularis "ro"ria 1an

inner circular layer and an outer lon!itudinal layer' com"risin! 2 narro$ ands3' and 1*3 serosa& Clinical Detail": Rectal cancers tend to e sym"tomatic earlier than colonic tumors& Dvert rectal leedin! is more common in rectal than colonic tumors& A chan!e in o$el ha it or sym"toms of lar!e o$el o struction' such as "ain and a dominal distension' may e the "resentin! features in "atients $ith a rectosi!moid or u""er rectal tumor& )he "rimary tumor may e "al"a le y di!ital e+amination of the rectum& >ei!ht loss' #aundice' and ascites are associated $ith advanced metastatic disease& Perforation is rare ut may occur as a result of distension "ro+imal to the tumor 1usually in the cecum3 or locally at the site of the tumor& Pneumaturia and feculent va!inal dischar!e may occur as a result of fistula formation into the ladder or va!ina&

Possi ly asym"tomatic Pal"a le mass on di!ital rectal e+amination Dvert rectal leedin! Microcytic anemia $ith fati!ue' shortness of reath' and an!ina Ea!ue a dominal discomfort Chan!e in o$el ha it Bar!e o$el o struction Pneumaturia 4eculent va!inal dischar!e Perforation 1rare3 >ei!ht loss 5aundice Ascites

Preferred /-amination: %valuation e!ins $ith a history and "hysical e+amination' includin! a di!ital rectal e+amination&

Ins"ect the stool and test for occult lood& Drder lood tests' ie' com"lete lood count' liver function tests' and carcinoem ryonic anti!en levels& Perform either si!moidosco"y 1ri!id or fle+i le3 or a dou le-contrast arium enema& Perform C) studies to sta!e the tumor "rior to treatment to choose the most a""ro"riate treatment& Althou!h MRI is sli!htly more accurate than C) in sta!in! "rimary rectal tumors' C) is much more $idely availa le& Most institutions and de"artments have more e+tensive e+"erience usin! C) than MRI and continue to use C) for sta!in! rectal tumors& )his may chan!e in the future&

0imitation" of Techni$ue":

Si!moidosco"y/ )he :,-cm fle+i le si!moidosco"e has an increased ran!e over the ri!id si!moidosco"e' $hich at est reaches only to the rectosi!moid #unction 17, cm3& )he si!moidosco"e also is more accurate in the rectum& Si!moidosco"y detects smaller adenomatous "oly"s than arium enema@ "oly"s may e e+cised y this method& Dou le-contrast arium enema/ Detects most colorectal tumors 1;,-<*-3 ut should e "receded y fle+i le si!moidosco"y& It has a lo$ "erforation rate 19F7*',,,3& C) and MRI cannot e used to assess the e+act de!ree of mural invasion of the "rimary rectal tumor& )hese techni?ues cannot distin!uish enlar!ed lym"h nodes resultin! from tumor from those resultin! from inflammation& Normal-si6ed nodes containin! tumor cannot e detected y either techni?ue&
Section 1 of 11

DI##/R/NTI.0S

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

Carcinoid' (astrointestinal Colon' Poly"s Crohn Disease %ndometriomaF%ndometriosis Ulcerative Colitis Other Pro'lem" to 'e Con"idered: %+trinsic com"ression y ad#acent neo"lasm or eni!n mass includin! endometrioma Bym"homa involvin! the rectum 2)R.3
Section 4 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

#inding": Dou le-contrast arium enema

Most rectal cancers are 2-8 cm in diameter at dia!nosis& Poly"oid lesions vary from small smooth tumors to lar!er lo ulated masses $ith an irre!ular surface and associated contour deformity alon! one mar!in of the o$el $all 1see Ima!e 93& Annular lesions result from irre!ular circumferential masses that severely

constrict the o$el lumen& Mar!ins of the carcinoma sho$ overhan!in! ed!es' $hich are the tumor shelf or shoulder 1see Ima!e 73& Mucosal folds in the narro$ed se!ment are destroyed' and ulceration may e "resent& 4lat lesions are rare and consist of a unilateral road- ased contour defect& Ulceration may e "resent& 4lat lesions may infiltrate the o$el $all' and' if e+tensive' cause areas of nondistensi ility&

%arly carcinomaF"oly"s

Small carcinoma usually "resent as a "oly"oid mass $ith a smooth outline and may e indistin!uisha le from a eni!n "oly"& Rarely' they may "resent as a small flat lesion&

Radiolo!ic a""earances

A "oly"oid mass is visuali6ed radiolo!ically either as a fillin! defect in the arium column 1sin!le contrast study3 or more commonly as a ariumcoated soft tissue mass "rotrudin! into the air-filled lumen 1dou le contrast study3& A sessile "oly" may e visuali6ed as a crescent 1or rin!3 shado$ on the o$el $all& Bo ulation is common in "oly"oid lesions lar!er than 7 cm in diameter& Pedunculated "oly"s have stal.s that may e identified easily on "rofile& >hen the stal. is o served throu!h the "oly" itself' this results in a tar!et 1or Me+ican hat3 a""earance& Mali!nant chan!e may occur in the head of a stal.ed "oly"& A lon! 17 cm or more3 thin 1* mm or less3 stal. may hinder the s"read of carcinoma from the head of the "oly" into the $all&

Ris. of mali!nancy )he ris. of mali!nancy in a "oly" increases $ith its si6e& It is less than 9in "oly"s less than 9 cm in diameter& )his increases to *- in 9-7 cm adenomas& Poly"s lar!er than 7 cm have a ris. of 99-*,-& )hus' all ,&*-2 cm "oly"oid lesions re?uire endosco"ic removal and histolo!ic e+amination& Bocal com"lications of the "rimary tumor

A lar!e o$el o struction usually results from an annular carcinoma in the u""er rectum or rectosi!moid #unction& A locali6ed "erforation resultin! from tumor necrosis may result in a "ararectal a scess that simulates an inflammatory "rocess& Perforation also may occur "ro+imal to an o structin! tumor' usually in the cecum& Bocal invasion of ad#acent or!ans 1 ladder' uterus' va!ina3 and fistula

formation are late manifestations& Synchronous lesions

A""ro+imately *- of colorectal cancers demonstrate multi"le lesions at dia!nosis& An adenomatous "oly" is "resent else$here in the colon or rectum in 2*of "atients dia!nosed $ith a "rimary colorectal carcinoma& Second tumors are more li.ely to e overloo.ed 1Gsatisfaction of search errorH3&

Plain a dominal radio!ra"hs

)hese are useful in "atients "resentin! $ith lar!e o$el o struction or "erforation& 4ree !as under the dia"hra!m is detected est y a "lain erect chest radio!ra"h& Rarely' mucin-"roducin! colonic cancers demonstrate calcification in the "rimary tumor and in he"atic and "eritoneal secondary de"osits&

Degree of Confidence: Dou le-contrast arium enema detects a""ro+imately <,- of rectal tumors& )he overall detection rate for sin!le-contrast arium enema is a""ro+imately ;,- ut is much lo$er for small "oly"oid tumors& #al"e Po"iti*e"&Negati*e": 4alse-"ositive e+aminations may result' since residual stool may e adherent to the o$el $all and mimic a tumor& A su mucosal mass' such as a li"oma or eni!n mucosal adenoma or hy"er"lastic "oly"' may e indistin!uisha le from a small "oly"oid cancer& 4alse-ne!ative e+aminations may result from inade?uate o$el "re"aration in $hich multi"le fillin! defects resultin! from residual stool may o scure carcinoma& In this case' re"eat e+amination or si!moidosco"y is re?uired& Small lesions may e missed in a dense "ool of arium& %rrors of "erce"tion account for more than *,- of missed cancers& )hese can e reduced y as.in! a different o server to "erform a second readin!& Multi"le cancers can "roduce false ne!atives' since second lesions are more li.ely to e overloo.ed 1Gsatisfaction of search errorH3& Strictures resultin! from inflammatory o$el disease' diverticulitis and radiation colitis may mimic mali!nant strictures& %+trinsic com"ression of the rectum y an ad#acent mass may mimic a "rimary rectal tumor&

C.T SC.N

Section ( of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

#inding": Indications for "erformin! C) in rectal carcinoma

C) is used for sta!in! the rectal carcinoma "rior to treatment' for sta!in! of recurrent disease' and for detectin! the "resence of distant metastases after sur!ery& In older "atients $ho may e una le to under!o colonosco"y or arium enema' modified C) is "erformed for "rimary detection of colorectal tumors& Rectal tumors may e dia!nosed on C) as an incidental findin!&

)umor sta!in! C) sta!in! 1see )a le 73 or )NM sta!in! 1see )a le 23 systems may e used to assess colonic neo"lasms& )a le 7& C) Sta!in! System 4or Rectal CancerA Stage )9 )7 )2a )2 )8 De"cri tion Intraluminal "oly"oid mass@ no thic.enin! of o$el $all )hic.ened rectal $all I: mm@ no "erirectal e+tension )hic.ened rectal $all "lus invasion of ad#acent muscle or or!ans )hic.ened rectal $all "lus invasion of "elvic side $all or a dominal $all Distant metastases' usually liver or adrenal

AModified from )hoeni 1Radiolo!y' 9<;93 )a le 2& )NMFModified Du.es Classification SystemA

TN% Stage )9 N, M, )7 N, M, )2 N, M, )7 N9 M, )2 N9 M, )8 Any )' M9

%odified Duke" Stage A B9 B7 C9 C7 C7 D

De"cri tion Bimited to su mucosa Bimited to muscularis "ro"ria )ransmural e+tension )7' enlar!ed mesenteric nodes )2' enlar!ed mesenteric nodes Invasion of ad#acent or!ans Distant metastases "resent

AModified from the American 5oint Committee on Cancer 19<<C3 4indin!s on C)

)he rectal tumor often is o served as a focal mass of soft tissue density ad#acent to the !as-filled or (astro!rafin-filled o$el lumen& Dral $atersolu le contrast 19- (astro!rafin3 is administered 97 hours and 7 hours "rior to e+amination to o"acify the entire o$el& Mali!nant strictures are detected y a thic.enin! of the o$el $all 1see Ima!e 23& )his thic.enin! is concentric if the scannin! "lane is at ri!ht an!les to the lon! a+is of the rectum 1see Ima!e 83& %+trarectal tumor s"read is su!!ested y a loss of tissue fat "lanes et$een the rectum and surroundin! tissues as $ell as "erirectal fat strandin! and nodularity& Invaded muscle may e enlar!ed& Small strands of tissue may e+tend from the rectal $all into the "erirectal fat&

Sta!in! N Sta!in! o Nodes !reater than 9, mm in diameter are considered a normal& C) is una le to distin!uish enlar!ed nodes from eni!n causes from

enlar!ed mali!nant nodes& 4urthermore' mali!nant foci may e "resent in nodes less than 9 cm in diameter& o Dverall' :,- of affected nodes are detected y C)& o %nlar!ed nodes may e detected in the mesentery and retro"eritoneum& Rectal tumors may metastasi6e to internal iliac nodes& M Sta!in! o 0e"atic metastases are the most common site of distant s"read& C) detects he"atic metastases as $ell-defined areas of lo$ density 1com"ared to normal liver "arenchyma3 in the "ortal venous "hase follo$in! in#ection of intravenous contrast medium 1see Ima!e *3& In the earlier arterial "hase' he"atic metastases may demonstrate rim enhancement or ecome hy"erdense or isodense 1in relation to normal liver3& o 0e"atic metastases may e suita le for sur!ical resection if they are small 1usually J2 cm3' num er less than 2' and are suita ly located' ut others are only suita le for intra-arterial chemothera"y or radiofre?uency 1R43 a lation 1see Intervention3& o Pulmonary metastases are more fre?uent from lo$ rectal carcinomas than u""er rectal or colon carcinomas& )his is ecause lo$ rectal tumors drain into the systemic venous system 1via the internal iliac veins3 rather than into the "ortal venous system 1via the su"erior and inferior mesenteric veins3 li.e colon and u""er rectal cancers& )hus' lo$ rectal tumors may have "ulmonary metastases and no evidence of he"atic metastases& Althou!h "ulmonary metastases may e detected y chest radio!ra"h' C) has a hi!her sensitivity for small "ulmonary metastases 1J9, mm3& o Dther common sites include the adrenals' the "eritoneum' and omentum& Adrenal metastases may occur in as many as 98- of "atients $ith colonic carcinoma& )hey are manifested y enlar!ement 1I7 cm3' asymmetry' and hetero!eneity&

Bony and cere ral metastases are uncommon&

C) findin!s hel" determine sur!ical o"tions& Precise information concernin! the site and local e+tent of the tumor is re?uired efore the a""ro"riate sur!ical choice can e made& >ell-defined tumors 1)9 or )73 may e amena le to sim"le resection or lo$ anterior resection& More advanced tumors 1)23 may re?uire a domino"erineal resection or anterior resection' de"endin! on their location& Perio"erative ad#uvant radiothera"y or chemothera"y may e used&

Com"lications of the "rimary tumor

C) can demonstrate o struction' "erforation' and fistula formation& A local "erforation of a carcinoma may e associated $ith an e+traluminal fluid

collection& %arly cancers and "oly"s )umors less than 7 cm in diameter cannot e detected relia ly y standard C) techni?ues& C) colono!ra"hy or virtual colonosco"y $as introduced y Einin! in 9<<: as a screenin! tool for the detection of colorectal "oly"s and small cancers& It involves a 2-dimensional com"uter reconstruction from a volumetric data set usin! a $or.station as $ell as distendin! a clean colon $ith air& Ima!es are read as soft-co"y from the $or.station usin! a com ination of "a!in!throu!h the 7D a+ial ima!es' aided y multi"lanar and 2D endoluminal ima!es& )he recent arrival of multisectional helical scanners has reduced the time re?uired to o tain the ima!es 1usually 2, seconds for each series' scannin! the "atient "rone and su"ine usin! a reduced tu e current to minimi6e the radiation dose3& )he len!th of time re?uired for ima!e analysis 1currently ran!in! from *-2, minutes3 also has decreased $ith the introduction of so"histicated soft$are "ro!rams that ena le a Kmathematically-strai!htenedK colon to e vie$ed $hile co-referencin! the 2D ima!es $ith the cross sectional ima!es& Advances in com"uter-aided dia!nosis and novel methods of dis"lay are e+"ected to im"rove the "erformance of this test and reduce the readin! time& )he sensitivity of this recently introduced techni?ue is !reater than that of dou le-contrast arium enema& 4or "oly"s lar!er than 9, mm' it has a sensitivity of <9- ut a s"ecificity of C:-& )his sensitivity falls to ;9- for *9, mm "oly"s& C) findin!s in recurrent rectal cancer

A aseline C) study is o tained 2 months follo$in! resection of a rectal tumor& Recurrent tumor is sta!ed y similar criteria as descri ed a ove for "rimary cancers& )here is a local recurrence rate of 7,-8,- and a distant metastases rate of a""ro+imately 2*- after curative resection& Most of these occur $ithin 7 years of sur!ery& C) can e used to detect local recurrence as $ell as lym"hadeno"athy and distant metastases& C) criteria of a recurrent tumor include invasion of ad#acent structures' increasin! si6e' and associated lym"hadeno"athy 1see Ima!e :3& An inflammatory mass follo$in! sur!ery or radiation thera"y may mimic a recurrent tumor and may re?uire io"sy for differentiation 1see Ima!e C3& Posto"erative soft tissue masses usually are the result of !ranulation tissue ut may e from a hematoma or a scess& Df these' :,- decrease' ut 8,may remain unchan!ed for u" to 7 years& Both recurrent tumor and inflammatory masses can cause hydrone"hrosis

y ureteric o struction 1see Ima!e ;3& Degree of Confidence: C) is more accurate in assessin! )8 cancers@ ho$ever' the s"atial resolution of C) is too lo$ to distin!uish )7 from )2 lesions& C) has *,- sensitivity for local invasion ut does not distin!uish et$een direct tumor infiltration and an inflammatory reaction induced y the tumor& C) detects u" to :,- of mesenteric nodes ut is una le to detect tumor in normalsi6ed nodes 1J9 cm in diameter3@ in most lym"h nodes' metastases are less than 9 cm in diameter& Nodes may e enlar!ed for other reasons' such as infection& Rectal lesions smaller than 7 cm may not e detected& )he accuracy and ?uality of C) can e increased usin! intravenous 1IE3 contrast medium' rectal contrast 1air or (astro!rafin3' smooth muscle rela+ants' and la+atives& )he sensitivity of virtual colonosco"y or C) colono!ra"hy is !reater than that of dou le-contrast arium enema& 4or "oly"s lar!er than 9, mm' the techni?ue has a sensitivity of <9- 1;9- for *- to 9,-mm "oly"s3 ut a s"ecificity of C:-& Its future role in colorectal "oly" screenin! is assured& #al"e Po"iti*e"&Negati*e":

C) si!ns for rectal cancer are not s"ecific and may e caused y any disease associated $ith focal thic.enin! of the rectal $all' includin! Crohn disease& A "oly"oid mass may result from an adenoma' carcinoid tumor' or lym"homa rather than rectal carcinoma& In cachectic "atients' a sence of fat "lanes is a result of nutritional status and not tumor invasion& %nlar!ed lym"h nodes may result from inflammation rather than tumor& Bym"h nodes of normal si6e may contain tumor& 0y"odense he"atic lesions may e sim"le cysts rather than he"atic metastases& 0e"atic metastases do not enhance follo$in! in#ection of IEcontrast medium and a""ear as hy"odense lesions 1see Ima!e *' Ima!e ;3& Recurrent tumor 1see Ima!e :3 may e difficult to differentiate from "osto"erative fi rosis on ima!in! !rounds alone 1see Ima!e C3 and may re?uire io"sy& %RI
Section 5 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

#inding":

Rectal tumors have lo$ si!nal intensity 1similar to ad#acent s.eletal muscle3 on )9-$ei!hted se?uences' $hich facilitates their differentiation from hi!hsi!nal "erirectal fat 1see Ima!e <3&

)7-$ei!hted ima!es are used to detect "elvic side$all invasion& )umor enhancement can e achieved y "arama!netic a!ents such as !adolinium&

Degree of Confidence: MRI "rovides !reater contrast in soft tissues than C)& MRI is more accurate than C) at "reo"erative sta!in! of rectal and rectosi!moid tumors and in the detection of direct tumor s"read into the "erirectal fat and ad#acent "elvic or!ans& MRI and C) have similar overall accuracy in the detection of enlar!ed lym"h nodes 1N sta!in!3 and liver metastases& MRI has a hi!her sensitivity 1<9-3 than C) 1;7-3 in detectin! local recurrence and a hi!her s"ecificity 19,,-3 than C) 1:<-3& Nevertheless' most centers continue to use C) rather than MRI for sta!in! and follo$-u" ima!in! of rectal neo"lasms& )his is ecause of the $ider availa ility of C) and their much lon!er e+"erience $ith C)& )his is li.ely to chan!e in the future& )he ne$ techni?ue of MR colono!ra"hy can detect colonic "oly"s and may com"ete $ith C) colono!ra"hy in screenin! "ro!rams& U0TR.SOUND
Section 6 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

#inding": )he "rimary role of ultrasound 1US3 is in detectin! liver metastases& US sensitivity is as hi!h as ;*-& 0e"atic metastases resultin! from rectal carcinoma usually are hy"erechoic 1see Ima!e 9,3 ut may e hy"oechoic 1see Ima!e 993& Unli.e C) and MR' transrectal ultrasound 1)RUS3 can de"ict individual rectal $all layers& )he e+tent of s"read throu!h the rectal $all may e assessed y means of a rotatin! hi!h-fre?uency "ro e "laced in the rectum 1see Ima!e 973& )he rectal $all is visuali6ed as * concentric ands as follo$s/

Mucosa 1echo!enic3 Muscularis mucosa 1hy"oechoic3 Su mucosa 1echo!enic3 Muscularis "ro"ria 1hy"oechoic3 Serosa 1echo!enic3

)he rectal tumor is demonstrated as a hy"oechoic mass $ith varyin! mural invasion 1see Ima!e 923& Invasion of the ladder and "rostate and ad#acent lym"h nodes may e demonstrated& Bym"h nodes involved y tumor ecome s"herical and hy"odense rather than oval and hy"erdense' as is seen in normal lym"h nodes&

Degree of Confidence: )RUS is limited to lesions located less than 98 cm from the anus and may not e used for the u""er rectum& It may overestimate tumor si6e and e+tent as a result of tumoral inflammatory res"onse& S"read eyond the rectal $all to the "elvic cavity cannot e detected& )RUS only detects ad#acent lym"h nodes& )he sensitivity of )RUS for detection and local sta!in! of rectal tumors 1$ithin 98 cm of the anus3 is <,-9,,- 1C) is *,-;,-3' and its s"ecificity is C*- 1C) is 22;,-3& )RUS cannot assess the e+tent of any distant s"read eyond its narro$ ran!e& NUC0/.R %/DICIN/
Section 7 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

#inding": Nuclear medicine studies have an increasin! role in colorectal cancer& Radioimmuno!lo ulin scinti!ra"hy uses monoclonal anti ody that reco!ni6es carcinoem ryonic anti!en or tumor-associated !lyco"rotein C7 and may e used in the detection of disease recurrence in the "elvis or e+trahe"atic a domen& )his techni?ue is ein! re"laced y "ositron emission tomo!ra"hy 1P%)3& P%) may detect recurrent or metastatic disease usin! fluorine-9;fluorodeo+y!lucose 14-9;-4D(3& Degree of Confidence: A recent study 1Meta' 7,,93 evaluated the im"act of 4D( P%) on the mana!ement of "atients $ith colorectal carcinoma& )hey noted a chan!e in the clinical sta!e and ma#or mana!ement decisions in a""ro+imately 8,- of "atients& Df the chan!es in clinical sta!e in 7* "atients' the disease $as u"sta!ed in 7, "atients 1;,-3 and do$n-sta!ed in * "atients 17,-3& As a result of P%) findin!s' "hysicians avoided ma#or sur!ery in 89- of "atients for $hom sur!ery $as the intended treatment& #al"e Po"iti*e"&Negati*e": 4alse-"ositive results may occur $ith 4D( in "atients $ith a scesses from nons"ecific inflammatory reactions follo$in! radiothera"y or tracer u"ta.e in o$el' ladder' or ureters& INT/R8/NTION
Section 9 of 11

Author Information Introduction Differentials X-ray Cat Scan MRI Ultrasound Nuclear Medicine Intervention Pictures Bi lio!ra"hy

Inter*ention: Metallic stents may e "laced across o structin! carcinomas of the rectum as a tem"orary measure to reduce the need for emer!ency sur!ery& In "atients una le to under!o sur!ery or $ho have unresecta le tumors' stents are used as a "alliative "rocedure& Stent "lacement is a relatively sim"le "rocedure that ra"idly im"roves the !eneral condition of "atients $ith lar!e o$el o struction& In some institutions' intra-arterial chemothera"y via the internal iliac arteries is "erformed in "atients $ith unresecta le tumors& Similarly' intra-arterial chemothera"y via the he"atic artery may e used in the mana!ement of liver metastases from colorectal cancer& (uided liver-directed thera"y such as R4 a lation and interstitial laser "hotocoa!ulation cause "referential tumor necrosis& R4 electrodes or laser fi ers are inserted into the he"atic metastasis under C) or US control follo$ed y tumor a lation "rocedures& Promisin! results' 1e!' a 8,- *-year survival3' have een achieved from R4 thermal a lation in selected "atients $ith he"atic metastases from colorectal cancer& %edical&0egal Pitfall":

4ailure to reco!ni6e the si!ns and sym"toms of rectal cancer 4ailure to a""ro"riately screen "atients at various levels of ris. 4ailure to detect a carcinoma or "oly" 1I9, mm3 y dou le-contrast arium enema or si!moidosco"y 4ailure to sta!e the carcinoma correctly usin! C) or MRI