Preoperative staging of rectal cancer using a 7.5 MHz front-loading US probe

BACKGROUND

Conventional echoendoscopes have disadvantages when used for staging colorectal cancer including the inability to pass the instrument through tight stenosis and limited maneuverability. This study evaluated the preoperative use of a newly developed 7.5 MHz front-loading ultrasound probe (FLUP) for local staging of rectal cancer.

METHODS

A 7.5 MHz FLUP, diameter 7.3 mm, was used in this study. The mechanical shaft portion of the probe can be passed in retrograde fashion through the accessory channel of a standard colonoscope. Thirty-nine patients with rectal cancer underwent ultrasonography with this probe. The tumors were staged using the TNM system, and the results were compared with the histologic findings of the resected specimens.

RESULTS

The FLUP proved to be satisfactory, with respect to maneuverability, for traversing stenosis and accurate recognition of small tumors under direct endoscopic control. The accuracy of the FLUP for T staging was 82% (32 of 39) for all tumors, 90% in pT1, and 79% in pT2 to pT4 tumors. The accuracy of the FLUP for N staging was 72% (23 of 32) overall. The sensitivity was 83%, the specificity was 65%, the positive predictive value was 59%, and the negative predictive value was 87%.

CONCLUSIONS

The 7.5 MHz FLUP appears to be useful for preoperative local staging of rectal cancer. This system makes it technically easier to image small cancers as well as advanced rectal cancers.

Imaging of cystic lesions

Cystic neck masses are varied in their histology and embryogenesis. Because neural, vascular, and lipomatous lesions may all appear cystic, a multimodality imaging approach can help identify these potential mimics. Developmental neck cysts include thyroglossal duct, thymic, and branchial cleft cysts, and teratomatous lesions or lymphangiomas. Although laryngoceles are acquired lesions, congenital anomalies (e.g., abnormally long saccules) may play a role in their formation. Lesion location is at least as important a determinant as morphology in formulating the differential diagnosis of a cystic neck mass. Midline cystic lesions are most commonly thyroglossal duct cysts, although dermoid tumors are also frequently midline. Squamous cell carcinoma metastatic to anterior triangle lymph nodes (Fig. 17), and cystic, necrotic schwanommas, can mimic the typical appearance of an infected second branchial cleft cyst. Posterior triangle lymphadenopathy and lipomatous lesions may resemble cystic hygromas. Cystic-appearing masses in the carotid space include neurogenic tumors, vascular thromboses, and carotid chain lymphadenopathy. Neural-based lesions typically occur posterolateral to the carotid artery. Necrotic lymphadenopathy may be suggested by lesion multiplicity, or by the presence of ancillary features, such as systemic symptoms, or the existence of a primary tumor. It must be emphasized that the primary role of the radiologist in head and neck imaging is to help stage disease and guide surgery. Despite clinical and radiographic analysis, the diagnosis of many lesions ultimately depends on image-guided or excisional biopsy.

Neck ultrasound in staging squamous oesophageal carcinoma - a high yield technique

AIM

This study evaluates the use of neck ultrasound in staging squamous oesophageal carcinoma.

MATERIALS AND METHODS

A prospective analysis of the clinical, neck ultrasound (US) and thoraco-abdominal computed tomography (CT) findings in 121 patients with squamous oesophageal carcinoma at presentation was performed. The relationship between malignant neck nodes, mediastinal and abdominal adenopathy, location and size of the primary tumour was analysed.

RESULTS

Ten of 121 patients (8%) had clinically palpable neck nodes which were deemed malignant in six (5%) following US and fine-needle aspiration for cytology. Of those 111 patients with no palpable neck nodes, 31 (28%) had malignant nodes shown on US. The more cephalad the location of the primary tumour, the higher the frequency of malignant neck nodes which were found in 80%, 52%, 29% and 9% of cervical, upper thoracic, mid-thoracic and lower thoracic oesophageal tumours, respectively. Eleven (29%) of the 38 patients with malignant neck nodes shown on US had no CT evidence of additional adenopathy in the mediastinum or upper abdomen. Neck US altered TNM staging in 22/121 (18%) patients at presentation.

CONCLUSION

Neck US frequently detects clinically impalpable metastatic nodes leading to altered TNM staging in patients with squamous oesophageal carcinoma. We advocate its routine use when staging squamous oesophageal carcinoma.

Asymptomatic congenital oesophageal cyst infiltrating the lung: an unusual complication

An asymptomatic 14-year-old boy presented with minor chest trauma. Chest X-ray showed opacity in the upper zone of the left lung. Further investigations with magnetic resonance imaging showed it to be a posterior mediastinal mass with a fistula to the lung, along with cystic changes in the left upper lobe of lung. Left upper lobectomy with excision of the mass was performed. Histological examination later showed an oesophageal duplication cyst with a fistula to the left upper lobe of the lung. We present this unusual complication of an oesophageal cyst infiltrating the lung in an asymptomatic child.

Endosonographic staging of 100 consecutive patients with esophageal carcinoma: introduction of the 8-mm esophagoprobe

Endoscopic ultrasound of esophageal carcinoma is conventionally performed using the 13-mm fiberoptic/ultrasound echoendoscope. However, the large diameter results in an inability to negotiate the primary tumor in 25% of patients. The aim of this study was first to determine whether use of the 8-mm esophagoprobe would overcome this problem and second to evaluate the accuracy of the smaller diameter instrument. One hundred consecutive patients with esophageal cancer underwent initial gastroscopy. Based upon the degree of luminal stenosis, patients were staged with either the conventional echoendoscope (luminal diameter > or = 15 mm) or the esophagoprobe (luminal diameter < 15 mm). The primary tumor was successfully negotiated in all subjects (echoendoscope 30, esophagoprobe 70) so that T- and N-staging was accomplished in every patient. Esophageal dilatation was performed in 12 patients (12%). The procedure was well tolerated and there were no complications, in particular no patient suffered esophageal perforation. The accuracy of the esophagoprobe for T-staging was 90% (19 out of 20) and that for N-staging was 75% (15 out of 20). This was similar to the accuracy of staging with the conventional echoendoscope, 90% (9 out of 10) for T-stage and 90% (9 out of 10) for N-stage. The esophagoprobe can safely and accurately stage patients with esophageal carcinoma, including those with high-grade stenoses.

Surgery for complete rectal prolapse in adults

BACKGROUND

Complete rectal prolapse is a debilitating condition, which affects both the very young and the elderly and can cause faecal incontinence. The range of surgical methods available to correct the underlying anal sphincter or pelvic floor defects in complete rectal prolapse poses the question about the choice of the best operation.

OBJECTIVES

To determine the effects of surgery on the treatment of rectal prolapse in adults. The following specific issues have been addressed: I. Whether surgical intervention is better than no treatment; II. Whether an abdominal approach to surgery is better then a perineal approach; III. Whether one method for performing rectopexy is better than another; IV. Whether laparoscopic access is better than open access for surgery; V. Whether resection should be included in the procedure.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We hand searched the British Journal of Surgery 1995-8, and the Diseases of the Colon and Rectum 1995-8. We also searched the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent searches: March 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of rectal prolapse.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature, extracted data and assessed the methodological quality of eligible trials. The three primary outcome measures were number of patients with recurrent rectal prolapse, or residual mucosal prolapse or faecal incontinence.

MAIN RESULTS

Eight trials were included with a total of 264 participants. No trial included a group receiving no treatment, or anal encirclement, or Delormes procedure, or laparoscopic suture rectopexy, or laparoscopic resection rectopexy. One trial (20 participants) compared both perineal and abdominal resection rectopexy with pelvic floor repair; four trials (175 participants) compared different types of open rectopexy techniques; one trial (21 participants) compared laparoscopic with open mesh rectopexy; and two trials included comparisons between open resection rectopexy and rectopexy alone. In all comparisons data were few. There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although there was a suggestion that residual faecal incontinence was less common after abdominal surgery. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation, although these findings were found in small numbers. There were too few data with which to compare laparoscopic with open surgery. Bowel resection during rectopexy was associated with lower rates of constipation, but again numbers were small.

REVIEWER'S CONCLUSIONS

The small number of relevant trials identified, and their small sample sizes together with other methodological weaknesses severely limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment.

Do we practice what we preach? clinical decision making and utilization of endoscopic ultrasound for staging esophageal cancer

OBJECTIVES

Endosonography is accurate for staging esophageal cancer. However, whether detailed staging impacts clinical decision making, whether endosonography is perceived as a useful modality, and what factors influence the utilization of endosonography have not been studied.

METHODS

One hundred gastroenterologists were surveyed about staging and management of esophageal cancer, including: 1) management by stage; 2) perceived usefulness of endosonography; 3) availability of endosonography; and 4) number of patients referred.

RESULTS

Clinical decisions varied by incremental differences in tumor stage. However, only 27 of 66 respondents (40.9%) judged endosonography to be very useful or essential for the evaluation of esophageal cancer and only 22 (33.3%) had referred a patient. Perceived usefulness and availability were independent factors strongly associated with referral for endosonography. Among 18 respondents to whom endosonography was available and who considered it useful, 14 (77.9%) had referred a case. In contrast, a conservative management was not associated with either perceived usefulness of or referral for endosonography.

CONCLUSIONS

Clinicians recognize the importance of detailed staging for management of esophageal cancer. Despite this, they underestimate the utility of endosonography and fail to refer patients for appropriate evaluation. Lack of perceived usefulness and unavailability are important independent barriers to utilization of endosonography in clinical practice.

Esophageal cancer

Carcinoma of the esophagus and gastroesophageal junction continues to be an aggressive cancer with poor prognosis, despite improved surgical results and the potential benefit of combined multimodality regimens. Additional data seem to confirm the rising incidence of adenocarcinoma, although users of nonsteroidal anti-inflammatory drugs seem to have a decreased risk. Much attention is focused on detecting high-grade dysplasia and early carcinoma with promising results using red fluorescence after preceding 5-aminolevulinic acid (ALA) sensitization. Positron emission tomography made a major breakthrough and seems to be superior to computed tomography in detecting distant metastasis as well as lymph node metastasis. Endoscopic ablation of early carcinoma results in promising early results, but a major issue remains the EUS discrimination between Tis-T1a and T1b, as the latter is frequently associated with lymph node metastasis. In the field of molecular biology, research is unraveling the role of cadherins and catenins in the mechanism underlying cell adherence, cell movement, and progress toward tumor formation. Mutations of p53 are correlated with loss of apoptosis and form an early step in progress toward carcinoma as well as mutations of other tumor-suppressing genes (eg, p16 and Rb mutations). Detection of such mutations may become useful prognostic indicators, but illustrate the genetic polymorphism influencing the susceptibility to carcinoma. Several lines of evidence suggest that the stabilizing or overriding of p53 mutant cancer cells and restoration of the wild-type tumor suppressor gene p53 may improve results of DNA damaging treatment modalities. Further research in this field may lead to new forms of anticancer therapy.

Mediastinal hibernoma

A 46-year-old asymptomatic male was detected to have a posterior mediastinal mass on a routine check-up. He underwent thoracotomy to remove the mass, which was found to be a hibernoma. The mediastinum is an extremely rare site for an even rarer tumor like the hibernoma. An additional unique feature was the very large tumor size despite which the patient was asymptomatic. Imaging studies are not helpful in revealing its clinically indeterminate nature, hence a surgical specimen is necessary to establish the correct diagnosis. Total excision is advocated for cure, as there is no known malignant potential.

Endosonographic Staging of Esophageal Cancer

BACKGROUND: Endosonography (ES) is an important tool for staging malignant esophageal cancer with the TNM staging classification. ES is a safe procedure and an accurate method of staging tumor invasion (T) and lymph node involvement (N). METHODS: The author reviewed the literature on the comparative roles of computed tomography and ES as complementary staging procedures. RESULTS: Advantages of ES in staging esophageal cancer include the ability to accurately determine the layer depth of mural infiltration and to detect metastatic involvement of regional lymph nodes. Its disadvantages include its inability to identify distant metastases, to differentiate inflammation from malignant infiltration of wall layers or in lymph nodes, and to examine beyond obstructing tumors unless esophageal dilation is performed. A recent review indicates the accuracy for T staging to be 84% and N staging to be 77%. CONCLUSIONS: ES is a valuable tool in staging esophageal cancer and should be used in combination with computed tomography for highest accuracy.

Esophageal carcinoma. Ex vivo endoluminal magnetic resonance imaging

RATIONALE AND OBJECTIVES

The authors evaluate ex vivo the role of endoluminal magnetic resonance imaging (MRI) in the tumor and regional lymph node staging of esophageal carcinoma.

MATERIALS AND METHODS

Nine esophagus specimens with carcinoma (seven adenocarcinoma, two squamous cell carcinoma) were studied directly after resection. Tumor (T) and regional lymph nodes (N) were classified, and the results were compared to histopathology.

RESULTS

T classification with endoluminal MRI was correct in eight of the nine tumors. One Tis tumor was staged as T1 tumor because of submucosal edema. MRI detected 35 of 91 lymph nodes. Of these 35 nodes, 14 were true-positives, 5 were false-positives, 1 was a false-negative, and 15 were true-negatives. The majority of the 56 missed lymph nodes were outside the field of view, including two specimens with a tight stricture. These lymph nodes included seven nodes with metastatic involvement. TN classification was correct in six specimens (67%).

CONCLUSION

This ex vivo pilot study demonstrates that T classification of esophageal carcinoma using endoluminal MRI is feasible. The results of lymph node classification are less favorable, predominantly because of the limited field of view.