Perspective on the Role of Transrectal and Transvaginal Sonography of Tumors of the Rectum and Anal Canal
Francesca Berton1,2,
Giada Gola1,3 and
Stephanie R. Wilson1,4
1 Section of Ultrasound, Department of Medical Imaging, Toronto General
Hospital, University of Toronto, Toronto, ON, Canada.
2 Present address: Institute of Radiology, IRCCS San Matteo Hospital, University
of Pavia, Pavia Italy.
3 Present address: Serves di Radiologia, Ospedale Civile di Voghera, Voghera,
Pavia, Italy.
4 Department of Diagnostic Imaging, Foothills Medical Centre, 1403 29 St. NW,
Calgary, AB, Canada T2N 2T9.
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Fig. 1A —71-year-old woman with biopsy-proven tubulovillous adenoma
who has undergone unsuccessful transrectal sonography. Images show advantages
of biplane transducer technology, use of sodium phosphate enema, addition of
color Doppler, and transvaginal scanning. Axial transrectal sonographic image
shows soft mass on left wall of rectum outlined by fluid in rectum from sodium
phosphate enema and evident on real-time examination.
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Fig. 1B —71-year-old woman with biopsy-proven tubulovillous adenoma
who has undergone unsuccessful transrectal sonography. Images show advantages
of biplane transducer technology, use of sodium phosphate enema, addition of
color Doppler, and transvaginal scanning. Color transrectal sonographic image
confirms presence of lesion.
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Fig. 2A —62-year-old woman with very small T1 rectal lesion. Images
show advantages of biplane transducer technology, use of sodium phosphate
enema, addition of color Doppler, and transvaginal scan. After normal findings
on transrectal sonography, axial sonographic image of rectum obtained with
transvaginal probe shows subtle superficial hypoechoic mass on left
anterolateral wall. Submucosa and muscularis propria are intact.
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Fig. 2B —62-year-old woman with very small T1 rectal lesion. Images
show advantages of biplane transducer technology, use of sodium phosphate
enema, addition of color Doppler, and transvaginal scan. Color Doppler image
confirms vascularity of lesion. Small superficial tumor can be difficult to
find with transrectal sonography and other imaging techniques.
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Fig. 3A —Anatomy of rectum and anal canal. Coronal schematic shows
caudal extent of rectum in anal canal. Thin black line in rectal wall,
representing muscularis propria, becomes thicker black internal anal sphincter
at anorectal junction. Fibers of levator ani muscle contribute to external
sphincter.
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Fig. 4B —Normal layers of bowel wall. Bowel wall in cross section
(B) and long axis (C).On sonography wall consists of alternating
layers of echogenicity and hypoechogenicity beginning on inside with echogenic
layer that represents mucosal interface. Dominant echogenic layer is
submucosa, and each hypoechoic layer contains muscle fibers.
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Fig. 4C —Normal layers of bowel wall. Bowel wall in cross section
(B) and long axis (C).On sonography wall consists of alternating
layers of echogenicity and hypoechogenicity beginning on inside with echogenic
layer that represents mucosal interface. Dominant echogenic layer is
submucosa, and each hypoechoic layer contains muscle fibers.
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Fig. 5 —42-year-old man who has undergone successful excision of
rectal carcinoid. Follow-up sagittal transrectal sonographic image obtained
with biplane linear rectal probe shows five layers of normal rectal wall.
Muscle layers are hypoechoic, and submucosa is dominant echogenic layer. Fluid
is present within rectal lumen, which appears black. Perirectal fat appears
echogenic or white.
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Fig. 6 —Schematic shows T component of TNM staging of rectal cancer.
Tumors are red and exhibit progressively deeper invasion beginning at
10-o'clock position, where T superficial noninvasive lesion involves only
superficial layers of intestinal wall. At 7-o'clock position, T1 lesion
invades submucosa (yellow). At 5-o'clock position, T2 lesion invades
muscularis propria (blue). At 2-o'clock position, T3 lesion exhibits
full-thickness invasion through layers of rectal wall with invasion of
surrounding perirectal fat. In directly anterior aspect (12-o'clock position),
T4 lesion exhibits invasion of prostate gland.
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Fig. 7A —42-year-old woman with small palpable mass on left anterior
rectal wall found at digital rectal examination that proved to be T1
adenocarcinoma of rectum. Curved axial (A) and linear sagittal
(B) transrectal sonographic images show superficial hypoechoic tumor
with subtle involvement of echogenic submucosa.
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Fig. 7B —42-year-old woman with small palpable mass on left anterior
rectal wall found at digital rectal examination that proved to be T1
adenocarcinoma of rectum. Curved axial (A) and linear sagittal
(B) transrectal sonographic images show superficial hypoechoic tumor
with subtle involvement of echogenic submucosa.
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Fig. 8 —56-year-old man with early T3 rectal carcinoma imaged with
biplane rectal probe. Axial transrectal sonographic image shows hypoechoic
tumor that has destroyed submucosa and muscularis propria. Gross extension of
tumor into perirectal fat is evident. Echogenic margins (arrows) of
remaining submucosa are present on each side of invasive tumor.
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Fig. 9 —64-year-old man with extensive T3 mucinous rectal
adenocarcinoma. Axial transrectal sonographic image shows destruction of
submucosa, echogenic edge (arrow) of which is evident on right side
of image. Enlarged round perirectal node shows a hypoechoic tumor deposit.
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Fig. 10 —57-year-old man with invasive rectal cancer. Axial
transrectal sonographic image shows large anterior T4 invasive malignant tumor
of rectum with destruction of all wall layers and extension into perirectal
fat. Hypoechoic tumor is in intimate contact with posterior wall of prostate,
seemingly pushing it forward. Prostate involvement suspected on transrectal
sonography was confirmed on MRI.
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Fig. 11 —56-year-old woman with invasive rectal cancer who had
undergone undocumented incomplete transanal excision of polyp 10 years
previously. Transvaginal axial sonographic image shows hypoechoic solid
lobulated mass in anovaginal septum appearing almost independent of rectal
wall that represents incompletely excised polyp with malignant change and
regrowth over long interval.
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Fig. 12A —58-year-old man with T2 rectal cancer. This case illustrates
contribution of color Doppler imaging to tumor differentiation. Axial
transrectal sonographic image shows hypoechoic tumor. Destruction of submucosa
is evident with involvement of muscularis propria on right side of image.
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Fig. 12B —58-year-old man with T2 rectal cancer. This case illustrates
contribution of color Doppler imaging to tumor differentiation. Color Doppler
transrectal sonographic image at default setting shows typical
hypervascularity. Color demarcates tumor from normal rectal wall on left side
of image. Technique is helpful for tumor staging.
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Fig. 13A — 55-year-old man with small rectal adenocarcinoma originating
in adenomatous polyp of posterior rectal wall. This case illustrates
contribution of color Doppler imaging to tumor differentiation. Axial
transrectal sonographic image shows isoechoic polypoid mass with broad base
surrounded by fluid within rectal lumen. Mass involves submucosal layer
only.
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Fig. 13B — 55-year-old man with small rectal adenocarcinoma originating
in adenomatous polyp of posterior rectal wall. This case illustrates
contribution of color Doppler imaging to tumor differentiation. Color Doppler
image shows profuse vascularity and vascular stalk of polypoid mass.
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Fig. 14A —58-year-old woman with tubulovillous adenoma. This case
illustrates contribution of color Doppler imaging to tumor differentiation.
Axial transvaginal sonographic image shows mixed echogenic mass that seems to
fill lumen of rectum. There is no evidence of invasive cancer.
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Fig. 14B —58-year-old woman with tubulovillous adenoma. This case
illustrates contribution of color Doppler imaging to tumor differentiation.
Color Doppler image shows characteristic stellate vascularity frequently
encountered with this pathologic condition.
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Fig. 15A —64-year-old man with rectal lymphoma and known disseminated
lymphoma with gastrointestinal involvement. Axial transrectal sonographic
image of posterior rectal wall shows mucosa and submucosal layers are intact,
excluding possibility of adenocarcinoma. Hypoechoic tumor is extensive and
involves deep layers of rectal wall with diffuse extension into perirectal fat
evident as many hypoechoic bands.
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Fig. 15B —64-year-old man with rectal lymphoma and known disseminated
lymphoma with gastrointestinal involvement. Axial CT image through rectum
shows diffuse wall thickening and infiltration of perirectal fat. Layers of
involvement are not defined.
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Fig. 16A —47-year-old woman with melanoma of anal canal who presented
with tumor prolapsing from anal canal. Axial transrectal sonographic image of
rectum immediately above anorectal junctions shows very black tumor.
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Fig. 17 —59-year-old woman with asymptomatic gastrointestinal stromal
tumor found at routine physical examination. Transrectal sonographic image
shows solid, well-defined, round mass arising from muscularis propria. Tumor
is growing with submucosal pattern, and mucosal surface bulges into
fluid-filled lumen.
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Fig. 18A —60-year-old man with stenotic high T3 rectal carcinoma.
Endorectal probe could not pass through stenotic lumen. Biplane capability of
probe allowed accurate measurement and staging of tumor in all planes.
Long-axis transrectal sonographic image obtained with end-fired component
shows large circumferential rectal tumor.
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Fig. 18B —60-year-old man with stenotic high T3 rectal carcinoma.
Endorectal probe could not pass through stenotic lumen. Biplane capability of
probe allowed accurate measurement and staging of tumor in all planes. Axial
transrectal sonographic image shows residual strictured lumen represented by
small amount of echogenic air. Wall is circumferentially thickened and
hypoechoicwith no residual normal wall layers. Invasion of perirectal fat is
evident.
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Fig. 19A —62-year-old woman with cancer of anal canal. (Reprinted from
[4]) Sagittal sonographic image
of anal canal obtained with transvaginal probe shows focal hypoechoic mass in
outer third of anterior wall of anal canal.
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Copyright © 2008 by the American Roentgen Ray Society.
