Advertisement

International Journal of Colorectal Disease

, Volume 22, Issue 10, pp 1261–1268 | Cite as

Preoperative staging of rectal carcinoma by endorectal ultrasound: is there a learning curve?

  • S. A. BadgerEmail author
  • P. B. Devlin
  • P. J. D. Neilly
  • R. Gilliland
Original Article

Abstract

Background and aims

Endorectal ultrasound (ERUS) is becoming an essential tool in the management of rectal cancer. However, accuracy in the assessment of disease staging may be dependent on operator experience. The aim of this study was to determine if a learning curve exists.

Materials and methods

From October 1999 to December 2004, all patients with rectal cancer had a pre-operative ERUS performed by a single radiologist. ERUS staging was compared with post-operative pathology findings using the tumour, node, metastases (TNM) classification. The accuracy of ERUS in tumour (T) and node (N) staging after each additional consecutive ten patients was calculated.

Results

One hundred and thirty one patients were investigated by ERUS, of which 36 were excluded, leaving 95 patients in the study (60 men). Overall accuracy for T staging was 71.6%. No improvement with experience was noted (p > 0.05). With regard to T staging, ERUS tended to overstage more frequently than understage (24.2 versus 4.2%). The sensitivity, specificity, positive predictive value and negative predictive value of uT3 staging were 96.6, 33.3, 70.4 and 85.7%, respectively. Overall accuracy of uN staging was 68.8%. ERUS tended to overstage nodal disease more frequently than understage (16.1 versus 15.1%). Sensitivity, specificity, positive predictive value and negative predictive value were calculated for ultrasound-detected nodal disease (73.2, 62.2, 74.5 and 60.5%, respectively). Nodal staging accuracy improved from 50% after assessment of 10 cases to 77% after 30 cases were examined.

Conclusions

ERUS is an accurate method for staging rectal cancer pre-operatively. Accurate assessment of tumour stage can be achieved immediately by an experienced radiologist without specific training in ERUS. Nodal staging accuracy tends to improve with experience but reaches a plateau after 30 cases.

Keywords

Endorectal ultrasound Learning curve 

References

  1. 1.
    Carlsson U, Lasson A, Ekelund G (1987) Recurrence rates after curative surgery for rectal carcinoma, with special reference to their accuracy. Dis Colon Rectum 30:431–434PubMedCrossRefGoogle Scholar
  2. 2.
    Rich T, Gunderson LL, Lew R, Galdibini JJ, Cohen AM, Donaldson G (1983) Patterns of recurrence of rectal cancer after potentially curative surgery. Cancer 52:1317–1329PubMedCrossRefGoogle Scholar
  3. 3.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 69:613–616PubMedCrossRefGoogle Scholar
  4. 4.
    Ridgway PF, Darzi AW (2003) The role of total mesorectal excision in the management of rectal cancer. Cancer Control 10:205–211PubMedGoogle Scholar
  5. 5.
    Kapiteijn E, Marijnen CAM, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Dutch Colorectal Cancer Group et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646PubMedCrossRefGoogle Scholar
  6. 6.
    Camma C, Guinta M, Fiorica F, Pagliaro L, Craxi A, Cottone M (2000) Preoperative radiotherapy in resectable rectal cancer: a meta-analysis. JAMA 284:1008–1015PubMedCrossRefGoogle Scholar
  7. 7.
    Colorectal Cancer Collaborative Group (2001) Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet 358:1291–1304CrossRefGoogle Scholar
  8. 8.
    Swedish Rectal Cancer Trial (1997) Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 336:980–987CrossRefGoogle Scholar
  9. 9.
    Frykholm GJ, Glimelius B, Pahlman L (1993) Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomised trial and an evaluation of late secondary effects. Dis Colon Rectum 36:564–572PubMedCrossRefGoogle Scholar
  10. 10.
    Williams NS, Durdey P, Quirke P, Robinson PJ, Dyson JE, Dixon MF, Bird CC (1985) Preoperative staging of rectal neoplasm and its impact on clinical management. Br J Surg 72:868–874PubMedCrossRefGoogle Scholar
  11. 11.
    Nicholls RJ, Maxon AY, Morson BC, Dixon AK, Fry IK (1982) The clinical staging of rectal cancer. Br J Surg 69:404–409PubMedCrossRefGoogle Scholar
  12. 12.
    Korkolis DP, Plataniotis GD, Gondikakis E, Xinopoulos D, Koulaxouzidis GV, Katsilieris J, Vassilopoulos PP (2006). Short-term preoperative radiotherapy is a safe approach for treatment of locally advanced rectal cancer. Int J Colorectal Dis 21:1–6PubMedCrossRefGoogle Scholar
  13. 13.
    Schaffin DM, Wong WD (2004) Endorectal ultrasound in the preoperative evaluation of rectal cancer. Clin Colorectal Cancer 4:124–132Google Scholar
  14. 14.
    Rifkin MD, Wechsler RJ (1986) A comparison of computed tomography and endorectal ultrasound in staging rectal cancer. Int J Colorectal Dis 1:219–223PubMedCrossRefGoogle Scholar
  15. 15.
    Kramann B, Hildenbrandt U (1986) Computed tomography versus endosonography in staging of rectal carcinoma: a comparative study. Int J Colorectal Dis 54:655–659Google Scholar
  16. 16.
    Beynon J, Mortensen NJ, Foy DM, Channer JL, Virjee J, Goddard P (1986) Preoperative assessment of local invasion in rectal cancer: digital examination, endoluminal sonography or computed topography? Br J Surg 73:1015–1017PubMedCrossRefGoogle Scholar
  17. 17.
    Dixon AK, Fry IK, Morson BC, Nicholls RJ, Mason AY (1981) Preoperative computed tomography of carcinoma of the rectum. Br J Radiol 54:655–659PubMedCrossRefGoogle Scholar
  18. 18.
    Kim NK, Choi JS, Sohn SK, Min JS (1994) Transrectal ultrasonography in preoperative staging of rectal cancer. Yonsei Med J 35:396–403PubMedGoogle Scholar
  19. 19.
    Beynon J, Foy DMA, Temple LN, Channer JL, Virjee J, Mortensen NJMcC (1986) The endoscopic appearances of normal colon and rectum. Dis Colon Rectum 29:810–813PubMedCrossRefGoogle Scholar
  20. 20.
    Hildenbrandt U, Feifel G (1985) Preoperative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum 28:42–46CrossRefGoogle Scholar
  21. 21.
    Beynon J, Mortensen NJ, Foy DM, Channer JL, Rigby HS, Virjee J (1989) Preoperative assessment of mesorectal lymph node involvement in rectal cancer. Br J Surg 76:276–279PubMedCrossRefGoogle Scholar
  22. 22.
    Nesbakken A, Lovig T, Lunde OC, Nygaard K (2003) Staging of rectal carcinoma with transrectal ultrasonography. Scand J Surg 92:125–129PubMedGoogle Scholar
  23. 23.
    Bali C, Nousias V, Fatouros M, Stefanou D, Kappas AM (2004) Assessment of local stage in rectal cancer using endorectal ultrasonography (EUS). Tech Coloproctology 8(Suppl 1):s170–s173CrossRefGoogle Scholar
  24. 24.
    Garcia-Aguilar J, Pollack J, Lee SH, Hernandez de Anda E, Mellgren A, Wong WD, Finne CO, Rothenberger DA, Madoff RD (2002) Accuracy of endorectal ultrasonography in preoperative staging of rectal tumours. Dis Colon Rectum 45:10–15PubMedCrossRefGoogle Scholar
  25. 25.
    Tio TL, Tygat GN (1984) Endoscopic ultrasonography in the assessment of intra- and transmural infiltration of tumours in the oesphagus, stomach and papilla of Vater and in the detection of extraoephageal lesions. Endoscopy 16:203–210PubMedCrossRefGoogle Scholar
  26. 26.
    Hildenbrandt U, Klein T, Feifel G, Schwarz HP, Koch B, Schmitt RM (1990) Endosonography of pararectal lymph nodes: in vitro and in vivo evaluation. Dis Colon Rectum 33:863–868CrossRefGoogle Scholar
  27. 27.
    Glaser F, Layer G, Zuna I, van Kaick G, Schlag P, Herfarth C (1990) Preoperative assessment of perirectal lymph nodes by ultrasound. Chirurg 61:587–591PubMedGoogle Scholar
  28. 28.
    Kruskal JB, Kane RA, Sentovich SM, Longmaid HE (1997) Pitfalls and sources of error in staging rectal cancer with endorectal US. Radiographics 17:609–626PubMedGoogle Scholar
  29. 29.
    Herzog U, von Flue M, Tondelli P, Schuppisser JP (1993) How accurate is endorectal ultrasound in the preoperative staging of rectal cancer? Dis Colon Rectum 36:127–134PubMedCrossRefGoogle Scholar
  30. 30.
    Sunouchi K, Sakaguchi M, Higuchi Y, Naniki K, Muto T (1998) Limitation of endorectal ultrasonography: what does a low lesion more than 5 mm in size correspond to histologically? Dis Colon Rectum 41:761–764PubMedCrossRefGoogle Scholar
  31. 31.
    Katsura Y, Yamada K, Ishizawa T, Yoshinaka H, Shimazu H (1992) Endorectal ultrasonography for the assessment of wall invasion and lymph node metastasis in rectal cancer. Dis Colon Rectum 35:362–368PubMedCrossRefGoogle Scholar
  32. 32.
    Spinelli P, Schiavo M, Meroni E, Di Felice G, Andreola S, Gallino G, Belli F, Leo E (1999) Results of EUS in detecting perirectal lymph node metastases of rectal cancer: the pathologist makes the difference. Gastrointest Endosc 49:754–758PubMedCrossRefGoogle Scholar
  33. 33.
    Herrera-Ornelas L, Justiniano J, Castillo N, Peterelli N, Stulc J, Mittelman A (1987) Metastases in small lymph nodes from colon cancer. Arch Surg 122:1253–1256PubMedGoogle Scholar
  34. 34.
    Orrom WJ, Wong WD, Rothenberger DA, Jensen LL, Goldberg SM (1990) Endorectal ultrasound in the preoperative staging of rectal tumours. Dis Colon Rectum 33:654–659PubMedCrossRefGoogle Scholar
  35. 35.
    Kim JC, Yu CS, Jung HY, Kim HC, Kim SY, Park SK, Kang GH, Lee MG (2001) Source of errors in the evaluation of early rectal cancer by endoluminal ultrasonography. Dis Colon Rectum 44:1302–1309PubMedCrossRefGoogle Scholar
  36. 36.
    Yamashita Y, Machi J, Shirouzu K, Morotomi T, Isomoto H, Karegawa T (1998) Evaluation of endorectal ultrasound for the assessment of wall invasion of rectal cancer: report of a case. Dis Colon Rectum 31:617–623CrossRefGoogle Scholar
  37. 37.
    Kim NK, Kim MJ, Yun SH, Sohn SK, Min JS (1999) Comparative study of transrectal ultrasonography, pelvic computed tomography, and magnetic resonance imaging in preoperative staging of rectal cancer. Dis Colon Rectum 42:770–775PubMedCrossRefGoogle Scholar
  38. 38.
    Maier AG, Barton PP, Neuhold NR, Herbst F, Teleky BK, Lechner GL (1997) Peritumoral tissue reaction at transrectal US as a possible cause of over staging: histopathologic correlation. Radiology 203:785–789PubMedGoogle Scholar
  39. 39.
    Sailer M, Leppert R, Bussen D, Fuchs KH, Thiede A (1997) Influence of tumor position on accuracy of endorectal ultrasound staging. Dis Colon Rectum 40:1180–1186PubMedCrossRefGoogle Scholar
  40. 40.
    Carmody BJ, Otchy DP (2000) Learning curve of transrectal ultrasound. Dis Colon Rectum 43:193–197PubMedCrossRefGoogle Scholar
  41. 41.
    Knaebel HP, Koch M, Feise T, Benner A, Kienle P (2005) Diagnostics of rectal cancer: endorectal ultrasound. Recent Results Cancer Res 165:46–57PubMedGoogle Scholar
  42. 42.
    Gualdi GF, Casciani E, Guadalaxara A, d’Orta C, Polettini E, Pappalardo G (2000) Local staging of rectal cancer with transrectal ultrasound and endorectal magnetic resonance imaging. Comparison with histologic findings. Dis Colon Rectum 43:338–345PubMedCrossRefGoogle Scholar
  43. 43.
    Brown G (2000) The role of MRI in pre-operative staging of rectal cancer. Imaging 12:141–150Google Scholar
  44. 44.
    Brown G, Richards CJ, Newcombe RG, Dallimore NS, Radcliffe AG, Caey DP, Bourne MW, Williams GT (1999) Rectal carcinoma: thin section MR imaging for staging in 28 patients. Radiology 211:215–222PubMedGoogle Scholar
  45. 45.
    Branagan G, Chave H, Fuller C, McGee S, Finnis D (2004) Can magnetic resonance imaging predict circumferential margins and TNM stage in rectal cancer? Dis Colon Rectum 47:1317–1322PubMedCrossRefGoogle Scholar
  46. 46.
    Boyle KM, Petty D, Chalmers AG, Quirke P, Cairns A, Finan PJ, Sagar PM, Burke D (2005) MRI assessment of the bony pelvis may help predict resectability of rectal cancer. Colorectal Dis 7:232–240PubMedCrossRefGoogle Scholar
  47. 47.
    Fuchsjager MH, Maier AG, Schima W, Zebedin E, Herbst F, Mittlbock M, Wrba F, Lechner GL (2003) Comparison of transrectal sonography and double-contrast MR imaging when staging rectal cancer. Am J Roentgenol 181:421–427Google Scholar
  48. 48.
    Heindel W, Gossmann A, St Ernst, Schafer H, Kugel H, Krug B, Selzner M, Krahe T, Lackner K (1998) Endorectal MRI and ultrasonography in rectal tumors: correlation with histological staging. Rofo 168:573–579PubMedGoogle Scholar
  49. 49.
    Bianchi P, Ceriani C, Palmisano A, Pompili G, Passoni GR, Rottoli M, Cappellani A, Montorsi M (2006) A prospective comparison of endorectal ultrasound and pelvic magnetic resonance in the preoperative staging of rectal cancer. Ann Ital Chir 77:41–46PubMedGoogle Scholar
  50. 50.
    Chun HK, Choi D, Kim MJ, Lee J, Yun SH, Kim SH, Lee SJ, Kim CK (2006) Preoperative staging of rectal cancer: comparison of 3-T high-field MRI and endorectal sonography. Am J Roentgenol 187:1557–1562CrossRefGoogle Scholar
  51. 51.
    Manger T, Stroh C (2004) Accuracy of endorectal ultrasonography in the preoperative staging of rectal cancer. Tech Coloproctology 8(Suppl 1):s14–s15CrossRefGoogle Scholar
  52. 52.
    Kim JC, Kim HC, Yu CS, Han KR, Kim JR, Lee KH, Jang SJ, Lee SS, Ha HK (2006) Efficacy of 3-dimensional endorectal ultrasonography compared with conventional ultrasonography and computed tomography in preoperative rectal cancer staging. Am J Surg 192:89–97PubMedCrossRefGoogle Scholar
  53. 53.
    Morken JJ, Baxter NN, Madoff RD, Finne CO III (2006) Endorectal ultrasound-directed biopsy: a useful technique to detect local recurrence of rectal cancer. Int J Colorectal Dis 21(3):258–264PubMedCrossRefGoogle Scholar
  54. 54.
    Koch M, Antolovic D, Kienle P, Horstmann J, Herfarth C, von Knebel Doeberitz M, Weitz J (2006) Increased detection rate and potential prognostic impact of disseminated tumour cells in patients undergoing endorectal ultrasound for rectal cancer. Int J Colorectal Dis (Epub ahead of print)Google Scholar
  55. 55.
    Saitoh N, Okui K, Sarashina H, Suzuki M, Arai T, Nunomura M (1986) Evaluation of endographic diagnosis of rectal cancer using intrarectal ultrasonic examination. Dis Colon Rectum 29:234–242PubMedCrossRefGoogle Scholar
  56. 56.
    Rifkin MD, Ehrlich SM, Marks G (1989) Staging of rectal carcinoma: prospective comparison of endorectal US and CT. Radiology 170:319–322PubMedGoogle Scholar
  57. 57.
    Jochem RJ, Reading CC, Dozois RR, Carpenter HA, Charboneau W (1990) Endorectal ultrasonographic staging of rectal carcinoma. Mayo Clin Proc 65:1571–1577PubMedGoogle Scholar
  58. 58.
    Glaser F, Schlag P, Herfarth C (1990) Endorectal ultrasonography for the assessment of invasion of rectal tumours and lymph node involvement. Br J Surg 77:883–887PubMedCrossRefGoogle Scholar
  59. 59.
    Zammit M, Jenkins JT, Urie A, O’Dwyer PJ, Molloy RG (2005) A technically difficult endorectal ultrasound is more likely to be inaccurate. Colorectal Dis 7:486–491PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • S. A. Badger
    • 1
    Email author
  • P. B. Devlin
    • 2
  • P. J. D. Neilly
    • 1
  • R. Gilliland
    • 1
  1. 1.Department of SurgeryAltnagelvin Area HospitalLondonderryUK
  2. 2.Department of RadiologyAltnagelvin Area HospitalLondonderryUK

Personalised recommendations