Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Dec 20;29(1):29.
doi: 10.1007/s10151-024-03073-4.

Linear endo-ultrasonographic signs of muscularis propria invasion in early rectal cancer

F Ter Borg  1 , M E Bartelink  2 , A B Bruil  2 , M Ledeboer  2 , L M J W van Driel  3 , A Guitink  2   4 , J Faber  4
Affiliations

Linear endo-ultrasonographic signs of muscularis propria invasion in early rectal cancer

F Ter Borg et al. Tech Coloproctol. .

Abstract

Background and study aim: Local resection of early rectal cancer is being increasingly used. With invasion of the muscularis propria layer of the rectal wall, the risk of lymph node metastasis becomes too high to consider this the optimal oncological treatment. Therefore, a diagnosis of muscular invasion is important before attempting local resection; however, endoscopic and magnetic resonance imaging (MRI) images have limitations, such as overstaging (26-31%). We investigated the potential of linear endoscopic ultrasound (L-EUS) in the diagnosis of muscularis propria invasion.

Patients and methods: The study consisted of a development phase, in which linear (L)- EUS features, associated with muscular wall invasion were searched and tested, and a validation phase, during which 30 representative videos were assessed by the author F.t.B. and four experienced endosonographists without experience in rectal L-EUS.

Results: The development cohort consisted of 91 patients (2019-2023). Overall, six EUS features were found to be significantly associated with muscular wall invasion: tornado sign, blob sign, massive connection, layer split, extramural deposit, and, most importantly impaired shiftability between the lesion and muscularis propria layer. During the development phase, these findings demonstrated excellent diagnostic features (sensitivity, 94.4%; specificity, 97.9%; and overstaging, 4%). In the validation phase, the sensitivity, specificity, and overstaging by F.t.B. were 88%, 85%, and 12%, respectively. Among the four inexperienced reviewers, the percentages were 65%-71%, 46%-54%, and 33%-39%, respectively. When considering the 27 videos that were considered easy or moderately difficult to assess, only 55% were correctly interpreted by the inexperienced reviewers.

Conclusions: Linear endoscopic ultrasonography may be a valuable tool for the assessment of ingrowth into the muscularis propria in supposedly early rectal cancer, especially using its dynamic potential to assess fixation to the muscular wall by moving the lesion. However, training will be required to achieve satisfactory results.

Keywords: Endoscopic ultrasound; Oncological staging; Rectal cancer; Tumor infiltration depth.

PubMed Disclaimer

Conflict of interest statement

Declarations. Conflict of interest: The authors declare no competing interests. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Given the use of existing data, the study was not subject to the Medical Research Involving Humans Act. All patients gave written consent to the anonymous use of clinical data and EUS media for publication. Informed consent: For this type of study, formal consent is not required.

Figures

Fig. 1
Fig. 1
Tornado sign. There was a wedge-shaped extension from the lesion (violet) through the submucosa (blue) into the muscular wall (red). Note that the extension has the same echogenicity as the lesion, which is important when differentiating it from shadowing
Fig. 2
Fig. 2
Massive connection. There is a broad connection of between the lesion (violet) through the submucosa (blue) into the muscular wall. These are the most obvious cases
Fig. 3
Fig. 3
Blob sign. There is a nodular extension (violet), which disrupts the submucosa (blue) and the muscular wall (red). Notice again that the extension has the same echogenicity as the lesion. These nodular disruptions can be difficult to visualize
Fig. 4
Fig. 4
Layer split. The inner and outer muscular layer of the rectal wall (red) are torn apart by traction of the lesion (violet), which has iso-echogenic extension through the submucosa (blue) into the muscular wall. When the submucosa is clear, layer split is not a reliable sign of muscular wall invasion
Fig. 5
Fig. 5
Extramural deposit. There is an irregular deposit adjacent to the lesion (violet) outside the muscular wall
Fig. 6
Fig. 6
An example of unimpaired shiftabilty. Beneath the lesion (violet), the submucosa was visualized (blue) and below the submucosal layer the muscular wall was visualized (red). The sequential images demonstrate the excellent shiftability of the lesion over the muscularis propria layer using biopsy forceps (white line). Shifting directions are illustrated by arrows from the biopsy tip. This lesion showed only submucosal infiltration (T1)
Fig. 7
Fig. 7
An example of slightly impaired shiftability. A rectal lesion (violet) is visible at the tip of the endoscope. However, this time, the hyperechogenic submucosa was disrupted, and when moving the lesion with the endoscope, the muscular layer moved in parallel. This lesion was moved with the tip of the endoscope. Arrows point at the moving forces. The lesion had superficial muscular involvement (T2)
Fig. 8
Fig. 8
An example of massively impaired shiftability. A rectal lesion (violet) is visible with a massive connection to the muscular layer (red). Submucosal area (blue) has vanished almost completely. When moving the lesion with the tip of the endoscope, en-bloc movement occurs at the fixed muscular layer. Movement forces are denoted by arrows. This was a deep T2 lesion
See this image and copyright information in PMC

References

    1. Toes-Zoutendijk E, van Leerdam ME, Dekker E, van Hees F, Penning C, Nagtegaal I, van der Meulen MP, van Vuuren AJ, Kuipers EJ, Bonfrer JMG, Biermann K, Thomeer MGJ, van Veldhuizen H, Kroep S, van Ballegooijen M, Meijer GA, de Koning HJ, Spaander MCW, Lansdorp-Vogelaar I; Dutch National Colorectal Cancer Screening Working Group (2017) Real-time monitoring of results during first year of dutch colorectal cancer screening program and optimization by altering fecal immunochemical test cut-off levels. Gastroenterology 152:767–775 - PubMed
    1. Ushigome H, Ohue M, Kitamura M, Nakatsuka S, Haraguchi N, Nishimura J, Yasui M, Wada H, Takahashi H, Omori T, Miyata H, Yano M, Takiguchi S (2020) Evaluation of risk factors for lymph node metastasis in T2 lower rectal cancer to perform chemoradiotherapy after local resection. Mol Clin Oncol 12:390–394 - PMC - PubMed
    1. Dutch Guideline on completion surgery after local excision of colorectal cancer, 27-6-2023. https://richtlijnendatabase.nl/richtlijn/colorectaal_carcinoom_crc/prima...
    1. Tanaka S, Saitoh Y, Matsuda T, Igarashi M, Matsumoto T, Iwao Y, Suzuki Y, Nozaki R, Sugai T, Oka S, Itabashi M, Sugihara KI, Tsuruta O, Hirata I, Nishida H, Miwa H, Enomoto N, Shimosegawa T, Koike K (2021) Evidence-based clinical practice guidelines for management of colorectal polyps. J Gastroenterol. 10.1007/s00535-021-01776-1 - PMC - PubMed
    1. Mori Y, Kudo SE, Endo S, Maeda C, Mukai S, Maeda Y, Kataoka S, Takeda K, Ichimasa K, Miyachi H, Sawada N, Hidaka E, Ishida F (2016) Morphology as a risk factor for the malignant potential of T2 colorectal cancer. Mol Clin Oncol 5(3):223–226 - PMC - PubMed

Publication types

LinkOut - more resources