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Transvaginal Sonography as an Adjunct to Endorectal Sonography in the Staging of Rectal Cancer in Women

Kavita P. Dhamanaskar1,2, Wendy Thurston3 and Stephanie R. Wilson1

1 Department of Medical Imaging, Toronto General Hospital, University of Toronto, 585 University Ave., Toronto, ON M5G 2C4, Canada.
2 Present address: Diagnostic Imaging, Henderson General Hospital, Hamilton, ON L8V 1C3, Canada.
3 Department of Medical Imaging, St. Joseph's Health Centre, University of Toronto, Toronto, ON M6R 1B5, Canada.


Figure 1
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  		Fig. 1A —Advantages of sodium phosphate (Fleet Phospho-Soda, CB Fleet) enema. Transverse transvaginal sonographic (TVS) image of normal rectum in 62-year-old woman. Fluid (F) in rectal lumen appears black. Rectum is evident in its entirety as multilayered ring. All five layers of rectal wall are well delineated.

 

Figure 2
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  		Fig. 1B —Advantages of sodium phosphate (Fleet Phospho-Soda, CB Fleet) enema. Transverse TVS image of rectum in 67-year-old woman shows large polypoid rectal mass (M) outlined by enema solution (arrows).

 

Figure 3
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  		Fig. 2 —Schematic shows gut signature. Cross-sectional (left) and longitudinal (right) representations of histologic layers of gut wall that correspond to the five layers seen on a sonogram. Blue layers are hypoechoic, yellow and pink layers are hyperechoic.

 

Figure 4
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  		Fig. 3A —65-year-old woman with T2 N0 rectal carcinoma. Both scans show submucosa is penetrated by tumor and tumor involvement of muscularis propria. Arrows mark border of submucosa at margin of tumor. Endorectal sonogram obtained with axial rotating probe shows eccentric mass (M) between 11:30- and 4-o'clock positions. Mass obliterates submucosa and bulges deep border of wall but does not show extension into perirectal fat.

 

Figure 5
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  		Fig. 3B —65-year-old woman with T2 N0 rectal carcinoma. Both scans show submucosa is penetrated by tumor and tumor involvement of muscularis propria. Arrows mark border of submucosa at margin of tumor. Transvaginal sonogram shows mass (M) of similar size and location to that in A. Wall-layer definition is superior to and border of submucosa at margin of tumor (arrows) is better delineated than in A. Disruption of involved layers is evident.

 

Figure 6
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  		Fig. 4A —70-year-old woman with T3 N0 rectal carcinoma confirmed at surgery. Axial endorectal sonogram shows penetration of all rectal wall layers with irregularity of deep border of mass (M) into perirectal fat (arrows).

 

Figure 7
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  		Fig. 4B —70-year-old woman with T3 N0 rectal carcinoma confirmed at surgery. Transverse transvaginal sonogram shows concordant information with convincing evidence of irregular extension of tumor (M) into perirectal fat (arrows).

 

Figure 8
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  		Fig. 5A —76-year-old woman with gross T3 rectal carcinoma seen on transvaginal sonography (TVS) after failed endorectal sonography. Long-axis (A) and transverse (B) TVS images show large hypoechoic stenosing tumor with complete loss of wall-layer definition. Lumen (L) is narrowed. Gross invasion of perirectal fat (arrows) is evident in B.

 

Figure 9
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  		Fig. 5B —76-year-old woman with gross T3 rectal carcinoma seen on transvaginal sonography (TVS) after failed endorectal sonography. Long-axis (A) and transverse (B) TVS images show large hypoechoic stenosing tumor with complete loss of wall-layer definition. Lumen (L) is narrowed. Gross invasion of perirectal fat (arrows) is evident in B.

 

Figure 10
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  		Fig. 5C —76-year-old woman with gross T3 rectal carcinoma seen on transvaginal sonography (TVS) after failed endorectal sonography. Sagittal TVS image through mesorectum shows three lymph nodes (arrows) in perirectal fat. Patient underwent preoperative chemoradiation therapy.

 

Figure 11
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  		Fig. 6A —57-year-old woman with tubulovillous adenoma. Endorectal sonogram obtained with rotating axial probe shows eccentric mass (m) in anterior aspect between the 11-o'clock and 3-o'clock positions. Wall layering is not well defined at base of tumor, but tumor does not extend into perirectal fat. Polypoid intraluminal nature of mass is not evident because inflated rectal balloon compresses soft tumor into rectal wall. Arrowheads indicate submucosa.

 

Figure 12
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  		Fig. 6B —57-year-old woman with tubulovillous adenoma. Sagittal transvaginal sonogram shows polypoid intraluminal mass (m) outlined by enema fluid and clearly defined submucosa (arrowheads). Suggestion of wall disruption (arrow) is evident at base of stalk.

 

Figure 13
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  		Fig. 6C —57-year-old woman with tubulovillous adenoma. Projection in B with addition of color Doppler shows disruption is related to vascular stalk of tumor rather than tumor invasion through rectal wall.

 

Figure 14
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  		Fig. 7A —46-year-old woman with asymptomatic gastrointestinal stromal tumor. Sagittal transvaginal sonogram shows large hypoechoic mass (M) related to anterior rectal wall and arising from outer hypoechoic layer, muscularis propria. Submucosa is intact. Arrows outline two echogenic layers that constitute submucosa of anterior and posterior rectal wall. Luminal surfaces are in apposition and appear as gray line between two echogenic layers.

 

Figure 15
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  		Fig. 7B —46-year-old woman with asymptomatic gastrointestinal stromal tumor. Color Doppler image at same location as A confirms mass is solid and vascular.

 

Figure 16
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  		Fig. 8A —35-year-old woman with invasive rectal cancer and necrotic lymphadenopathy. Transverse transvaginal sonogram of rectovaginal septum shows two large nodes (arrows) with necrotic centers.

 

Figure 17
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  		Fig. 8B —35-year-old woman with invasive rectal cancer and necrotic lymphadenopathy. Axial CT scan shows two large nodes (long arrows) depicted in A and diffuse rectal wall thickening (short arrows) not shown in A.

 

Figure 18
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  		Fig. 9A —56-year-old woman with large stenotic rectal tumor. Endorectal sonographic examination failed. Transverse (A) and sagittal (B) transvaginal sonograms show extensive circumferential rectal wall tumor (T), destruction of wall layers, irregular residual lumen (arrows, A), and perirectal lymphadenopathy (arrows, B). Images show tumor only with no normal bowel wall. Lumen is obliterated and visible as central irregular white line related to residual luminal content, air, or both.

 

Figure 19
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  		Fig. 9B —56-year-old woman with large stenotic rectal tumor. Endorectal sonographic examination failed. Transverse (A) and sagittal (B) transvaginal sonograms show extensive circumferential rectal wall tumor (T), destruction of wall layers, irregular residual lumen (arrows, A), and perirectal lymphadenopathy (arrows, B). Images show tumor only with no normal bowel wall. Lumen is obliterated and visible as central irregular white line related to residual luminal content, air, or both.

 

Figure 20
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  		Fig. 10A —51-year-old woman with T2 cancer of rectosigmoid junction not seen on endorectal sonography. Transvaginal images show eccentric hypoechoic mass (m) in bowel. Destruction of echogenic wall layer represents submucosa with infiltration through hypoechoic muscularis propria. Perirectal fat is not invaded. Transverse image.

 

Figure 21
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  		Fig. 10B —51-year-old woman with T2 cancer of rectosigmoid junction not seen on endorectal sonography. Transvaginal images show eccentric hypoechoic mass (m) in bowel. Destruction of echogenic wall layer represents submucosa with infiltration through hypoechoic muscularis propria. Perirectal fat is not invaded. Long-axis image shows rectal wall layers opposite tumor are intact.

 

Figure 22
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  		Fig. 11A —62-year-old woman with cancer of anal canal. Transverse (A) and long-axis (B) transvaginal sonograms show hypoechoic mass (M) in anal canal close to anal verge. C, Color Doppler image shows intense vascularity of mass.

 

Figure 23
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  		Fig. 11B —62-year-old woman with cancer of anal canal. Transverse (A) and long-axis (B) transvaginal sonograms show hypoechoic mass (M) in anal canal close to anal verge.

 

Figure 24
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  		Fig. 11C —62-year-old woman with cancer of anal canal. Color Doppler image shows intense vascularity of mass.

 

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