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Nuernberg D, Saftoiu A, Barreiros AP, Burmester E, Ivan ET, Clevert DA, Dietrich CF, Gilja OH, Lorentzen T, Maconi G, Mihmanli I, Nolsoe CP, Pfeffer F, Rafaelsen SR, Sparchez Z, Vilmann P, Waage JER. EFSUMB Recommendations for Gastrointestinal Ultrasound Part 3: Endorectal, Endoanal and Perineal Ultrasound. Ultrasound Int Open 2019; 5:E34-E51. [PMID: 30729231 PMCID: PMC6363590 DOI: 10.1055/a-0825-6708] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 11/23/2018] [Accepted: 12/01/2018] [Indexed: 02/07/2023] Open
Abstract
This article represents part 3 of the EFSUMB Recommendations and Guidelines for Gastrointestinal Ultrasound (GIUS). It provides an overview of the examination techniques recommended by experts in the field of endorectal/endoanal ultrasound (ERUS/EAUS), as well as perineal ultrasound (PNUS). The most important indications are rectal tumors and inflammatory diseases like fistula and abscesses in patients with or without inflammatory bowel disease (IBD). PNUS sometimes is more flexible and convenient compared to ERUS. However, the technique of ERUS is quite well established, especially for the staging of rectal cancer. EAUS also gained ground in the evaluation of perianal diseases like fistulas, abscesses and incontinence. For the staging of perirectal tumors, the use of PNUS in addition to conventional ERUS could be recommended. For the staging of anal carcinomas, PNUS can be a good option because of the higher resolution. Both ERUS and PNUS are considered excellent guidance methods for invasive interventions, such as the drainage of fluids or targeted biopsy of tissue lesions. For abscess detection and evaluation, contrast-enhanced ultrasound (CEUS) also helps in therapy planning.
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Affiliation(s)
- Dieter Nuernberg
- Medical School Brandenburg Theodor Fontane, Gastroenterology, Neuruppin, Germany
| | - Adrian Saftoiu
- Research Center in Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Ana Paula Barreiros
- Deutsche Stiftung Organtransplantation, Head of Organisation Center Middle, Frankfurt, Germany
| | - Eike Burmester
- Department of Internal Medicine/Gastroenterology, Sana-Kliniken Lübeck, Lübeck, Germany
| | - Elena Tatiana Ivan
- Research Center in Gastroenterology and Hepatology, University of Medicine and Pharmacy Craiova, Craiova, Romania
| | - Dirk-André Clevert
- Department of Clinical Radiology, Interdisciplinary Ultrasound-Center, University of Munich-Grosshadern Campus, Munich, Germany
| | | | - Odd Helge Gilja
- National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Torben Lorentzen
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, “L.Sacco” University Hospital, Milan, Italy
| | - Ismail Mihmanli
- Istanbul University – Cerrahpasa, Cerrahpasa Medical Faculty, Department of Radiology and ALKA Radyoloji Tani Merkezi, Istanbul, Turkey
| | - Christian Pallson Nolsoe
- Ultrasound Section, Division of Surgery, Department of Gastroenterology, Herlev Hospital and Copenhagen Academy for Medical Education and Simulation (CAMES), University of Copenhagen, Denmark
| | - Frank Pfeffer
- Department of Surgery, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Søren Rafael Rafaelsen
- Colorectal Centre of Excellence, Clinical Cancer Centre, University Hospital of Southern Denmark, Vejle, Denmark
| | - Zeno Sparchez
- 3rd Medical Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Peter Vilmann
- Endoscopy Department, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Jo Erling Riise Waage
- Department of Surgery, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Kin C. So Now My Patient Has Squamous Cell Cancer: Diagnosis, Staging, and Treatment of Squamous Cell Carcinoma of the Anal Canal and Anal Margin. Clin Colon Rectal Surg 2018; 31:353-360. [PMID: 30397394 DOI: 10.1055/s-0038-1668105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Squamous cell carcinomas of the anal canal and the anal margin are rare malignancies that are increasing in incidence. Patients with these tumors often experience delayed treatment due to delay in diagnosis or misdiagnosis of the condition. Distinguishing between anal canal and anal margin tumors has implications for staging and treatment. Chemoradiation therapy is the mainstay of treatment for anal canal squamous cell, with abdominoperineal resection reserved for salvage treatment in cases of persistent or recurrent disease. Early anal margin squamous cell carcinoma can be treated with wide local excision, but more advanced tumors require a combination of chemoradiation therapy and surgical excision.
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Affiliation(s)
- Cindy Kin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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Meillan N, Huguet F, Peiffert D. [Follow-up after radiotherapy of anal canal carcinoma]. Cancer Radiother 2015; 19:610-5. [PMID: 26323891 DOI: 10.1016/j.canrad.2015.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/10/2015] [Accepted: 06/12/2015] [Indexed: 01/11/2023]
Abstract
Anal canal carcinoma is a rare and curable disease for which the standard of care is radiation therapy with concurrent 5-fluoro-uracil and mitomycine-based chemotherapy. Post-treatment follow-up however is rather poorly defined. This article offers a review of the various post-treatment surveillance options both for early diagnosis of relapse and care for late treatment effects. While follow-up remains mostly clinical, we will discuss morphologic (endorectal echoendoscopy, pelvic magnetic resonance imaging, tomodensitometry and positron emission tomography) and biologic (squamous cell carcinoma antigen and pathology) follow-up so as to determine their diagnostic and prognostic value.
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Affiliation(s)
- N Meillan
- Service d'oncologie radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
| | - F Huguet
- Service d'oncologie radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - D Peiffert
- Institut de cancérologie de Lorraine (Alexis-Vautrin), 6, avenue de Bourgogne, CS 30519, 54519 Vandœuvre-lès-Nancy cedex, France
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Abstract
BACKGROUND Evaluating patients for recurrent anal cancer after primary treatment can be difficult owing to distorted anatomy and scarring. Many institutions incorporate endoscopic ultrasound to improve detection, but the effectiveness is unknown. OBJECTIVE The aim of this study is to compare the effectiveness of digital rectal examination and endoscopic ultrasound in detecting locally recurrent disease during routine follow-up of patients with anal cancer. DESIGN This study is a retrospective, single-institution review. SETTINGS This study was conducted at an oncologic tertiary referral center. PATIENTS Included were 175 patients with nonmetastatic anal squamous-cell cancer, without persistent disease after primary chemoradiotherapy, who had at least 1 posttreatment ultrasound and examination by a colorectal surgeon. MAIN OUTCOME MEASURES The primary outcomes measured were the first modality to detect local recurrence, concordance, crude cancer detection rate, sensitivity, specificity, and predictive value. RESULTS Eight hundred fifty-five endoscopic ultrasounds and 873 digital rectal examinations were performed during 35 months median follow-up. Overall, ultrasound detected 7 (0.8%) mesorectal and 32 (3.7%) anal canal abnormalities; digital examination detected 69 (7.9%) anal canal abnormalities. Locally recurrent disease was found on biopsy in 8 patients, all detected first or only with digital examination. Four patients did not have an ultrasound at the time of diagnosis of recurrence. The concordance of ultrasound and digital examination in detecting recurrent disease was fair at 0.37 (SE, 0.08; 95% CI, 0.21-0.54), and there was no difference in crude cancer detection rate, sensitivity, specificity, and negative or positive predictive values. LIMITATIONS The heterogeneity of follow-up timing and examinations is not standardized in this study but is reflective of general practice. CONCLUSIONS Endoscopic ultrasound did not provide any advantage over digital rectal examination in identifying locally recurrent anal cancer, and should not be recommended for routine surveillance.
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Bedair EM, El Hennawy HM, Moustafa AA, Meki GY, Bosat BE. Transperineal sonographic anal sphincter complex evaluation in chronic anal fissures. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1981-1989. [PMID: 25336486 DOI: 10.7863/ultra.33.11.1981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the role of transperineal sonography in assessment of pathologic changes to the anal sphincter complex in patients with chronic anal fissures. METHODS We conducted a prospective case-control study of 100 consecutive patients of any age and both sexes with chronic anal fissures who presented to a colorectal clinic between January 2012 and August 2013 (group A) and 50 healthy volunteers (group B). RESULTS The most common patterns of radiologic changes to anal sphincters associated with chronic anal fissures were circumferential thickening of the anal sphincter complex in 5 patients (5%), circumferential thickening of the internal anal sphincter in 3 patients (3%), preferential thickening of the internal anal sphincter at the 6-o'clock position in 80 patients (80%) and the 12-o'clock position in 7 patients (7%), preferential thickening of the internal and external anal sphincters in 3 patients (3%), and thinning of the internal anal sphincter in 2 patients (2%). CONCLUSIONS Chronic anal fissures cause differential thickening of both internal and external anal sphincters, with a trend toward increased thickness in relation to the site of the fissure. Routine preoperative transperineal sonography for patients with chronic anal fissures is recommended, and it is mandatory in high-risk patients.
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Affiliation(s)
- Elsaid M Bedair
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Hany M El Hennawy
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.).
| | - Ahmed Abdu Moustafa
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Gad Youssef Meki
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
| | - Bosat Elwany Bosat
- Department of Radiology, Al Khor Hospital, Hamad Medical Corporation, Al Khor, Qatar (E.M.B.); Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar (H.M.E.H.); and Department of Surgery, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt (A.A.M., G.Y.M., B.E.B.)
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Strigård K, Gurmu A, Näsvall P, Påhlman P, Gunnarsson U. Intrastomal 3D ultrasound; an inter- and intra-observer evaluation. Int J Colorectal Dis 2013; 28:43-7. [PMID: 22772711 DOI: 10.1007/s00384-012-1526-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to determine intra- and interobserver reliability in 3D intrastomal ultrasound imaging of parastomal hernia and protrusion. METHOD A total of 40 patients were investigated. Two or three physicians evaluated the images twice, 1 month apart. RESULTS Inter-observer agreement was 72 % with a kappa value 0.59. For the last 10 patients there was an agreement of 80 % with a kappa value of 0.70. Intraobserver agreement was 80 % for one observer and 95 % for the other. The learning curve levelled out at around 30 patients. CONCLUSION Considering the learning curve of 30 patients, 3D intrastomal ultrasound is a reliable investigation method. 3D intrastomal ultrasonography has the potential to be the investigation of choice to differentiate between a bulge, a hernia, or a protrusion.
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Affiliation(s)
- K Strigård
- Department of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Karolinska University Hospital/Huddinge, Stockholm, Sweden.
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Zlobec I, Borner M, Lugli A, Inderbitzin D. Role of intra- and peritumoral budding in the interdisciplinary management of rectal cancer patients. Int J Surg Oncol 2012; 2012:795945. [PMID: 22900161 PMCID: PMC3415098 DOI: 10.1155/2012/795945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 06/23/2012] [Indexed: 01/30/2023] Open
Abstract
The presence of tumor budding (TuB) at the invasive front of rectal cancers is a valuable indicator of tumor aggressiveness. Tumor buds, typically identified as single cells or small tumor cell clusters detached from the main tumor body, are characterized by loss of cell adhesion, increased migratory, and invasion potential and have been referred to as malignant stem cells. The adverse clinical outcome of patients with a high-grade TuB phenotype has consistently been demonstrated. TuB is a category IIB prognostic factor; it has yet to be investigated in the prospective setting. The value of TuB in oncological and pathological practice goes beyond its use as a simple histomorphological marker of tumor aggressiveness. In this paper, we outline three situations in which the assessment of TuB may have direct implications on treatment within the multidisciplinary management of patients with rectal cancer: (a) patients with TNM stage II (i.e., T3/T4, N0) disease potentially benefitting from adjuvant therapy, (b) patients with early submucosally invasive (T1, sm1-sm3) carcinomas at a high risk of nodal positivity and (c) the role of intratumoral budding assessed in preoperative biopsies as a marker for lymph node and distant metastasis thus potentially aiding the identification of patients suitable for neoadjuvant therapy.
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Affiliation(s)
- Inti Zlobec
- Institute of Pathology, University of Bern, Murtenstrasse 31, 3010 Bern, Switzerland
| | - Markus Borner
- Department of Oncology, Hospital Centre Biel, 2502 Bienne, Switzerland
| | - Alessandro Lugli
- Institute of Pathology, University of Bern, Murtenstrasse 31, 3010 Bern, Switzerland
- Clinical Pathology Division, Institute of Pathology, University of Bern, Murtenstrasse 31, 3010 Bern, Switzerland
| | - Daniel Inderbitzin
- Department of Visceral and Transplantation Surgery, Inselspital-Bern University Hospital, 3010 Bern, Switzerland
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Gurmu A, Gunnarsson U, Strigård K. Imaging of parastomal hernia using three-dimensional intrastomal ultrasonography. Br J Surg 2011; 98:1026-9. [PMID: 21509751 DOI: 10.1002/bjs.7505] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Parastomal hernia is common in patients with a permanent stoma. At present there is no standard method for imaging a parastomal hernia. The aim of this study was to investigate the value of three-dimensional intrastomal ultrasonography in differentiating between a parastomal hernia and a bulge. METHODS Twenty patients were divided into four groups according to ultrasonography setting and probe cover. All patients were tested using three different ultrasound probe frequencies (9, 13 and 16 MHz). The intrastomal examination was performed during provocation in both the supine and upright positions, with a protector or water-containing balloon surrounding the probe. RESULTS The sharpest images were obtained using the rectal setting with a water-containing balloon surrounding the probe at 9 MHz in supine and erect positions, for evaluation of both fascia and muscle; in some instances even implanted mesh was detectable. When switched to render mode, the pictures improved in sharpness and it was easier to identify anatomical landmarks. CONCLUSION Intrastomal ultrasonography using the rectal setting and a frequency of 9 MHz is a feasible method for imaging a parastomal hernia and differentiating it from an abdominal bulge. The image quality improves when render mode is used.
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Affiliation(s)
- A Gurmu
- Department of Surgery, CLINTEC, Karolinska Institute at the Karolinska University Hospital, Huddinge, Stockholm, Sweden
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Abstract
Tumors of the anus and perianal skin are rare. Their presentation can vary and often mimics common benign anal pathology, thereby delaying diagnosis and appropriate and timely treatment. The anatomy of this region is complex because it represents the progressive transition from the digestive system to the skin with many different co-existing types of cells and tissues. Squamous cell carcinoma of the anal canal is the most frequent tumor found in the anal and perianal region. Less-frequent lesions include Bowen's and Paget's disease, basal cell carcinoma, melanoma, and adenocarcinoma. This article aims to review the clinical presentation, diagnostic evaluation, and treatment options for neoplasms of the anal canal and perianal skin.
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Affiliation(s)
- Daniel Leonard
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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