Rectal Carcinoma

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Last Updated: July 6, 2005
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Synonyms and related keywords: adenocarcinoma of the rectum, carcinoma of the rectum
AUTHOR INFORMATION Section 1 of 11
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Author: Isaac Hassan, MBChB, DMRD, FRCR, Clinical Director of Radiology,

Department of Radiology, Royal Bolton Hospital, UK
Isaac Hassan, MBChB, DMRD, FRCR, is a member of the following medical
societies: American Roentgen Ray Society, British Institute of Radiology, British
Medical Association, and Royal College of Radiologists
Editor(s): Ludwig G Strauss, MD, Associate Director, Professor, Department
of Innovative Cancer Diagnostics and Therapy, Clinical Cooper, German
Cancer Research Center; Bernard D Coombs, MBChB, PhD, Consulting
Staff, Department of Specialist Rehabilitation Services, Hutt Valley District
Health Board, New Zealand; Udo P Schmiedl, MD, PhD, Fellowship Director,
Professor, Department of Radiology, Division of Abdominal Imaging, University
of Washington Medical Center; Robert M Krasny, MD, Visiting Assistant
Professor of Radiology, University of California at Los Angeles Medical Center;
Consulting Staff, Healthcare Management Partners; and Eugene C Lin, MD,
Consulting Staff, Department of Radiology, Virginia Mason Medical Center

Disclosure

INTRODUCTION Section 2 of 11
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Background: Adenocarcinoma of the rectum is a major cause of mortality and

morbidity in North America and western Europe. Rectal cancers are, after colon
cancers, the second most common GI carcinoma and have the best prognosis.
The 5-year survival rate is approximately 50%. Screening for and removing
adenomatous polyps may improve survival rates. Almost all rectal cancers are
primary adenocarcinomas.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach,

and Intestine Center and Cancer and Tumors Center. Also, see eMedicine's
patient education articles, Colon Cancer, Colonoscopy, Sigmoidoscopy, and
Rectal Cancer.

Pathophysiology: Adenocarcinoma of the rectum arises as an intramucosal

epithelial lesion, usually in an adenomatous polyp or gland. As cancers grow,
they invade the muscularis mucosa and lymphatic and vascular structures to
involve regional lymph nodes, adjacent structures, and distant sites, especially
the liver.

Several factors increase the risk for rectal cancer, including the following:

• High-fat, low-fiber diet

• Patient older than 50 years
• Personal history of colorectal adenoma or carcinoma (3-fold risk)
• First-degree relative with colorectal cancer (3-fold risk)
• Familial polyposis coli, Gardner syndrome, and Turcot syndrome (in which
all patients without a colectomy develop colorectal carcinoma)
• Juvenile polyposis syndrome, Peutz-Jeghers syndrome, and Muir
syndrome (risk increased slightly)
• Hereditary nonpolyposis colorectal cancer (as many as 50% of patients
are affected)
• Inflammatory bowel disease
o Ulcerative colitis (risk is 30% after 25 y)
o Crohn disease (4- to 10-fold risk)

Frequency:

• In the US: Colorectal cancers are the second most common cause of
cancer death in developed countries and the most common GI cancer. In
2000, there were an estimated 130,200 new cases of colorectal cancer of
which 36,400 involved the rectum and 18,500 the rectosigmoid junction.
The highest GI cancer rates are in the Northeast and North Central states,
and the lowest rates are in the southern and western states (except for the
San Francisco Bay area and Hawaii, which have the highest incidence in
the United States).

Incidence rates, for colorectal cancer as a whole, declined significantly

during 1992-1996 (-2.1% per year). Research suggests that these declines
may be because of increased screening and polyp removal, preventing
progression of polyps to invasive cancers. The death rate also has
declined slightly.

• Internationally: The incidence of rectal cancer is highest in the

westernized countries of North America, northern Europe, Australia, and
New Zealand. Intermediate rates are found in southern Europe and low
rates in Africa, Asia, and South America. Rectal cancer shows less
international variation than colon cancer. While a 60-fold difference is
found in colon cancer incidence between countries with the highest and
lowest rates, only an 18-fold difference is found in incidence for rectal
 cancer. High colon-to-rectal cancer ratios (3-4:1) prevail in the westernized
countries of North America, northern Europe, Australia, and New Zealand.
Ratios equalling less than 1 are typical in Asia and Africa.

Mortality/Morbidity: Prognosis is related to the stage of the disease at diagnosis

and to initial treatment. Although a tumor, node, metastases (TNM) international
classification system and a staging CT system have been developed recently, the
Dukes classification (or one of its modifications) remains in wide use (see Table
1).

Prognosis also is affected by the histologic grade of the tumor. The complications
of rectal cancer include obstruction (common); fistula formation to small bowel,
bladder, or vagina (uncommon); and perforation (rare).

Table 1. Modified Dukes Classification System and 5-year Survival Rate*

5-yr Survival
Stage Description
Rate, %

A Limited to the bowel wall 83

Extension to pericolic fat;

B 70
no nodes

Regional lymph node

C 30
metastases

Distant metastases (liver,

D 10
lung, bone)

*Modified from Zinkin (Dis Colon Rectum, 1983)

Race:

• In the United States, rectal cancer incidence rates are higher in white
males than in black males, but the rates for white and black females are
similar. Colon cancer incidence rates also are similar among white and
black males and females.

• Risk rates rise for populations migrating from low-risk to high-risk areas, as
demonstrated clearly in Japanese immigrants in Hawaii and the
continental United States, where rates among immigrants have risen to
approximate those of the native population. The 18-fold difference in rectal
cancer rates between the country with the highest rate and the country
 with the lowest rate is significantly less than the 60-fold difference in colon
cancer rates. This may reflect dietary differences in fat and fiber intake in
different countries. These differences diminish when a western-type diet is
adopted.

Sex: An increased incidence exists in males in westernized countries. The male-

to-female ratio may vary from 8:7-9:5.

Age: Of patients with rectal carcinoma, 90% are older than 50 years. Only 5% of
patients are younger than 40 years.

Anatomy: The rectum lies anterior to the sacrum and coccyx and is
approximately 15 cm long. The rectosigmoid junction is located at the end of the
sigmoid mesocolon. Its upper third is covered almost completely by peritoneum.
Below this level, the peritoneum is reflected anteriorly onto the posterior surface
of the uterus and vagina in females and onto the posterior surface of the bladder
in males. The peritoneal recesses, the pouch of Douglas (rectouterine), and the
rectovesical pouch lie between these organs.

The lower half of the rectum is entirely extraperitoneal. The rectum ends just
below the level of the coccyx. It turns posteriorly through the puborectal sling of
the levator ani muscles to become the anal canal. The rectum is supplied by the
superior rectal branch of the inferior mesenteric artery and from branches of the
internal iliac arteries. The rectal lymphatics drain superiorly into the superior
rectal, then the inferior mesenteric nodes, and laterally into the internal iliac
nodes.

The rectal wall comprises 5 layers, including the (1) mucosa (lined with columnar
epithelium), (2) muscularis mucosa, (3) submucosa, (4) muscularis propria (an
inner circular layer and an outer longitudinal layer, comprising 3 narrow bands),
and (5) serosa.

Clinical Details: Rectal cancers tend to be symptomatic earlier than colonic

tumors. Overt rectal bleeding is more common in rectal than colonic tumors. A
change in bowel habit or symptoms of large bowel obstruction, such as pain and
abdominal distension, may be the presenting features in patients with a
rectosigmoid or upper rectal tumor. The primary tumor may be palpable by digital
examination of the rectum. Weight loss, jaundice, and ascites are associated with
advanced metastatic disease. Perforation is rare but may occur as a result of
distension proximal to the tumor (usually in the cecum) or locally at the site of the
tumor. Pneumaturia and feculent vaginal discharge may occur as a result of
fistula formation into the bladder or vagina.

• Possibly asymptomatic
• Palpable mass on digital rectal examination
• Overt rectal bleeding
 • Microcytic anemia with fatigue, shortness of breath, and angina
• Vague abdominal discomfort
• Change in bowel habit
• Large bowel obstruction
• Pneumaturia
• Feculent vaginal discharge
• Perforation (rare)
• Weight loss
• Jaundice
• Ascites

Preferred Examination: Evaluation begins with a history and physical

examination, including a digital rectal examination.

• Inspect the stool and test for occult blood.

• Order blood tests, ie, complete blood count, liver function tests, and
carcinoembryonic antigen levels.
• Perform either sigmoidoscopy (rigid or flexible) or a double-contrast barium
enema.
• Perform CT studies to stage the tumor prior to treatment to choose the
most appropriate treatment. Although MRI is slightly more accurate than
CT in staging primary rectal tumors, CT is much more widely available.
Most institutions and departments have more extensive experience using
CT than MRI and continue to use CT for staging rectal tumors. This may
change in the future.

Limitations of Techniques:

• Sigmoidoscopy: The 60-cm flexible sigmoidoscope has an increased

range over the rigid sigmoidoscope, which at best reaches only to the
rectosigmoid junction (20 cm). The sigmoidoscope also is more accurate in
the rectum. Sigmoidoscopy detects smaller adenomatous polyps than
barium enema; polyps may be excised by this method.
• Double-contrast barium enema: Detects most colorectal tumors (80-95%)
but should be preceded by flexible sigmoidoscopy. It has a low perforation
rate (1/25,000).
• CT and MRI cannot be used to assess the exact degree of mural invasion
of the primary rectal tumor. These techniques cannot distinguish enlarged
lymph nodes resulting from tumor from those resulting from inflammation.
Normal-sized nodes containing tumor cannot be detected by either
technique.

DIFFERENTIALS Section 3 of 11
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Carcinoid, Gastrointestinal
Colon, Polyps
Crohn Disease
Endometrioma/Endometriosis
Ulcerative Colitis

Other Problems to be Considered:

Extrinsic compression by adjacent neoplasm or benign mass including

endometrioma
Lymphoma involving the rectum

X-RAY Section 4 of 11
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Findings:

Double-contrast barium enema

• Most rectal cancers are 3-4 cm in diameter at diagnosis.

• Polypoid lesions vary from small smooth tumors to larger lobulated
masses with an irregular surface and associated contour deformity along
one margin of the bowel wall (see Image 1).
• Annular lesions result from irregular circumferential masses that severely
constrict the bowel lumen.
• Margins of the carcinoma show overhanging edges, which are the tumor
shelf or shoulder (see Image 2).
• Mucosal folds in the narrowed segment are destroyed, and ulceration may
be present.
• Flat lesions are rare and consist of a unilateral broad-based contour
defect. Ulceration may be present. Flat lesions may infiltrate the bowel
wall, and, if extensive, cause areas of nondistensibility.

Early carcinoma/polyps

• Small carcinoma usually present as a polypoid mass with a smooth outline

and may be indistinguishable from a benign polyp.
• Rarely, they may present as a small flat lesion.

Radiologic appearances

• A polypoid mass is visualized radiologically either as a filling defect in the

barium column (single contrast study) or more commonly as a barium-
 coated soft tissue mass protruding into the air-filled lumen (double contrast
study).
• A sessile polyp may be visualized as a crescent (or ring) shadow on the
bowel wall.
• Lobulation is common in polypoid lesions larger than 2 cm in diameter.
• Pedunculated polyps have stalks that may be identified easily on profile.
When the stalk is observed through the polyp itself, this results in a target
(or Mexican hat) appearance. Malignant change may occur in the head of
a stalked polyp. A long (2 cm or more) thin (5 mm or less) stalk may hinder
the spread of carcinoma from the head of the polyp into the wall.

Risk of malignancy

• The risk of malignancy in a polyp increases with its size. It is less than 1%
in polyps less than 1 cm in diameter. This increases to 5% in 1-2 cm
adenomas. Polyps larger than 2 cm have a risk of 11-50%. Thus, all 0.5-3
cm polypoid lesions require endoscopic removal and histologic
examination.

Local complications of the primary tumor

• A large bowel obstruction usually results from an annular carcinoma in the

upper rectum or rectosigmoid junction.
• A localized perforation resulting from tumor necrosis may result in a
pararectal abscess that simulates an inflammatory process.
• Perforation also may occur proximal to an obstructing tumor, usually in the
cecum.
• Local invasion of adjacent organs (bladder, uterus, vagina) and fistula
formation are late manifestations.

Synchronous lesions

• Approximately 5% of colorectal cancers demonstrate multiple lesions at

diagnosis.
• An adenomatous polyp is present elsewhere in the colon or rectum in 35%
of patients diagnosed with a primary colorectal carcinoma.
• Second tumors are more likely to be overlooked (“satisfaction of search
error”).

Plain abdominal radiographs

• These are useful in patients presenting with large bowel obstruction or

perforation.
• Free gas under the diaphragm is detected best by a plain erect chest
radiograph.
 • Rarely, mucin-producing colonic cancers demonstrate calcification in the
primary tumor and in hepatic and peritoneal secondary deposits.

Degree of Confidence: Double-contrast barium enema detects approximately

90% of rectal tumors. The overall detection rate for single-contrast barium enema
is approximately 80% but is much lower for small polypoid tumors.

False Positives/Negatives: False-positive examinations may result, since

residual stool may be adherent to the bowel wall and mimic a tumor. A
submucosal mass, such as a lipoma or benign mucosal adenoma or hyperplastic
polyp, may be indistinguishable from a small polypoid cancer.

False-negative examinations may result from inadequate bowel preparation in

which multiple filling defects resulting from residual stool may obscure carcinoma.
In this case, repeat examination or sigmoidoscopy is required.

Small lesions may be missed in a dense pool of barium. Errors of perception

account for more than 50% of missed cancers. These can be reduced by asking
a different observer to perform a second reading.

Multiple cancers can produce false negatives, since second lesions are more
likely to be overlooked (“satisfaction of search error”). Strictures resulting from
inflammatory bowel disease, diverticulitis and radiation colitis may mimic
malignant strictures. Extrinsic compression of the rectum by an adjacent mass
may mimic a primary rectal tumor.
 CAT SCAN Section 5 of 11
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Findings:

Indications for performing CT in rectal carcinoma

• CT is used for staging the rectal carcinoma prior to treatment, for staging of
recurrent disease, and for detecting the presence of distant metastases after
surgery.
• In older patients who may be unable to undergo colonoscopy or barium
enema, modified CT is performed for primary detection of colorectal tumors.
• Rectal tumors may be diagnosed on CT as an incidental finding.

Tumor staging

• CT staging (see Table 2) or TNM staging (see Table 3) systems may be

used to assess colonic neoplasms.

Table 2. CT Staging System For Rectal Cancer*

Stage Description

Intraluminal polypoid mass; no

T1
thickening of bowel wall

Thickened rectal wall >6 mm; no

T2
perirectal extension

Thickened rectal wall plus invasion of

T3a
adjacent muscle or organs

Thickened rectal wall plus invasion of

T3b
pelvic side wall or abdominal wall

Distant metastases, usually liver or

T4
adrenal

*Modified from Thoeni (Radiology, 1981)

Table 3. TNM/Modified Dukes Classification System*

 TNM Modified
Description
Stage Dukes Stage

T1 N0 Limited to
A
M0 submucosa

T2 N0 Limited to
B1
M0 muscularis propria

T3 N0 Transmural
B2
M0 extension

T2 N1 T2, enlarged
C1
M0 mesenteric nodes

T3 N1 T3, enlarged
C2
M0 mesenteric nodes

Invasion of
T4 C2
adjacent organs

Any T, Distant metastases

D
M1 present

*Modified from the American Joint Committee on Cancer (1997)

Findings on CT

• The rectal tumor often is observed as a focal mass of soft tissue density
adjacent to the gas-filled or Gastrografin-filled bowel lumen. Oral water-
soluble contrast (1% Gastrografin) is administered 12 hours and 2 hours
prior to examination to opacify the entire bowel.
• Malignant strictures are detected by a thickening of the bowel wall (see
Image 3). This thickening is concentric if the scanning plane is at right
angles to the long axis of the rectum (see Image 4).
• Extrarectal tumor spread is suggested by a loss of tissue fat planes between
the rectum and surrounding tissues as well as perirectal fat stranding and
nodularity.
• Invaded muscle may be enlarged.
• Small strands of tissue may extend from the rectal wall into the perirectal fat.

Staging

• N Staging
o Nodes greater than 10 mm in diameter are considered abnormal. CT
is unable to distinguish enlarged nodes from benign causes from
 enlarged malignant nodes. Furthermore, malignant foci may be
present in nodes less than 1 cm in diameter.
o Overall, 60% of affected nodes are detected by CT.
o Enlarged nodes may be detected in the mesentery and
retroperitoneum. Rectal tumors may metastasize to internal iliac
nodes.
• M Staging
o Hepatic metastases are the most common site of distant spread. CT
detects hepatic metastases as well-defined areas of low density
(compared to normal liver parenchyma) in the portal venous phase
following injection of intravenous contrast medium (see Image 5). In
the earlier arterial phase, hepatic metastases may demonstrate rim
enhancement or become hyperdense or isodense (in relation to
normal liver).
o Hepatic metastases may be suitable for surgical resection if they are
small (usually <3 cm), number less than 3, and are suitably located,
but others are only suitable for intra-arterial chemotherapy or
radiofrequency (RF) ablation (see Intervention).
o Pulmonary metastases are more frequent from low rectal carcinomas
than upper rectal or colon carcinomas. This is because low rectal
tumors drain into the systemic venous system (via the internal iliac
veins) rather than into the portal venous system (via the superior and
inferior mesenteric veins) like colon and upper rectal cancers. Thus,
low rectal tumors may have pulmonary metastases and no evidence
of hepatic metastases. Although pulmonary metastases may be
detected by chest radiograph, CT has a higher sensitivity for small
pulmonary metastases (<10 mm).
o Other common sites include the adrenals, the peritoneum, and
omentum. Adrenal metastases may occur in as many as 14% of
patients with colonic carcinoma. They are manifested by enlargement
(>2 cm), asymmetry, and heterogeneity.

Bony and cerebral metastases are uncommon.

• CT findings help determine surgical options. Precise information concerning

the site and local extent of the tumor is required before the appropriate
surgical choice can be made. Well-defined tumors (T1 or T2) may be
amenable to simple resection or low anterior resection. More advanced
tumors (T3) may require abdominoperineal resection or anterior resection,
depending on their location. Perioperative adjuvant radiotherapy or
chemotherapy may be used.

Complications of the primary tumor

• CT can demonstrate obstruction, perforation, and fistula formation. A local

perforation of a carcinoma may be associated with an extraluminal fluid
 collection.

Early cancers and polyps

• Tumors less than 2 cm in diameter cannot be detected reliably by standard

CT techniques.
• CT colonography or virtual colonoscopy was introduced by Vining in 1996 as
a screening tool for the detection of colorectal polyps and small cancers. It
involves a 3-dimensional computer reconstruction from a volumetric data set
using a workstation as well as distending a clean colon with air. Images are
read as soft-copy from the workstation using a combination of paging-
through the 2D axial images, aided by multiplanar and 3D endoluminal
images.
• The recent arrival of multisectional helical scanners has reduced the time
required to obtain the images (usually 30 seconds for each series, scanning
the patient prone and supine using a reduced tube current to minimize the
radiation dose). The length of time required for image analysis (currently
ranging from 5-30 minutes) also has decreased with the introduction of
sophisticated software programs that enable a "mathematically-straightened"
colon to be viewed while co-referencing the 3D images with the cross
sectional images.
• Advances in computer-aided diagnosis and novel methods of display are
expected to improve the performance of this test and reduce the reading
time.
• The sensitivity of this recently introduced technique is greater than that of
double-contrast barium enema. For polyps larger than 10 mm, it has a
sensitivity of 91% but a specificity of 76%. This sensitivity falls to 81% for 5-
10 mm polyps.

CT findings in recurrent rectal cancer

• A baseline CT study is obtained 3 months following resection of a rectal

tumor. Recurrent tumor is staged by similar criteria as described above for
primary cancers. There is a local recurrence rate of 20-40% and a distant
metastases rate of approximately 35% after curative resection. Most of these
occur within 2 years of surgery.
• CT can be used to detect local recurrence as well as lymphadenopathy and
distant metastases. CT criteria of a recurrent tumor include invasion of
adjacent structures, increasing size, and associated lymphadenopathy (see
Image 6).
• An inflammatory mass following surgery or radiation therapy may mimic a
recurrent tumor and may require biopsy for differentiation (see Image 7).
Postoperative soft tissue masses usually are the result of granulation tissue
but may be from a hematoma or abscess. Of these, 60% decrease, but 40%
may remain unchanged for up to 2 years.
 • Both recurrent tumor and inflammatory masses can cause hydronephrosis
by ureteric obstruction (see Image 8).

Degree of Confidence: CT is more accurate in assessing T4 cancers; however,

the spatial resolution of CT is too low to distinguish T2 from T3 lesions. CT has
50% sensitivity for local invasion but does not distinguish between direct tumor
infiltration and an inflammatory reaction induced by the tumor.

CT detects up to 60% of mesenteric nodes but is unable to detect tumor in normal-

sized nodes (<1 cm in diameter); in most lymph nodes, metastases are less than 1
cm in diameter. Nodes may be enlarged for other reasons, such as infection. Rectal
lesions smaller than 2 cm may not be detected. The accuracy and quality of CT can
be increased using intravenous (IV) contrast medium, rectal contrast (air or
Gastrografin), smooth muscle relaxants, and laxatives.

The sensitivity of virtual colonoscopy or CT colonography is greater than that of

double-contrast barium enema. For polyps larger than 10 mm, the technique has a
sensitivity of 91% (81% for 5- to 10-mm polyps) but a specificity of 76%. Its future
role in colorectal polyp screening is assured.

False Positives/Negatives:

• CT signs for rectal cancer are not specific and may be caused by any
disease associated with focal thickening of the rectal wall, including Crohn
disease. A polypoid mass may result from an adenoma, carcinoid tumor, or
lymphoma rather than rectal carcinoma.
• In cachectic patients, absence of fat planes is a result of nutritional status
and not tumor invasion.
• Enlarged lymph nodes may result from inflammation rather than tumor.
Lymph nodes of normal size may contain tumor.
• Hypodense hepatic lesions may be simple cysts rather than hepatic
metastases. Hepatic metastases do not enhance following injection of IV-
contrast medium and appear as hypodense lesions (see Image 5, Image 8).
• Recurrent tumor (see Image 6) may be difficult to differentiate from
postoperative fibrosis on imaging grounds alone (see Image 7) and may
require biopsy.

MRI Section 6 of 11
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Findings:

• Rectal tumors have low signal intensity (similar to adjacent skeletal muscle)
on T1-weighted sequences, which facilitates their differentiation from high-
signal perirectal fat (see Image 9).
 • T2-weighted images are used to detect pelvic sidewall invasion.
• Tumor enhancement can be achieved by paramagnetic agents such as
gadolinium.

Degree of Confidence: MRI provides greater contrast in soft tissues than CT. MRI
is more accurate than CT at preoperative staging of rectal and rectosigmoid tumors
and in the detection of direct tumor spread into the perirectal fat and adjacent pelvic
organs. MRI and CT have similar overall accuracy in the detection of enlarged
lymph nodes (N staging) and liver metastases.

MRI has a higher sensitivity (91%) than CT (82%) in detecting local recurrence and
a higher specificity (100%) than CT (69%). Nevertheless, most centers continue to
use CT rather than MRI for staging and follow-up imaging of rectal neoplasms. This
is because of the wider availability of CT and their much longer experience with CT.
This is likely to change in the future.

The new technique of MR colonography can detect colonic polyps and may
compete with CT colonography in screening programs.

ULTRASOUND Section 7 of 11
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Findings: The primary role of ultrasound (US) is in detecting liver metastases. US

sensitivity is as high as 85%. Hepatic metastases resulting from rectal carcinoma
usually are hyperechoic (see Image 10) but may be hypoechoic (see Image 11).

Unlike CT and MR, transrectal ultrasound (TRUS) can depict individual rectal wall
layers. The extent of spread through the rectal wall may be assessed by means of
a rotating high-frequency probe placed in the rectum (see Image 12).

The rectal wall is visualized as 5 concentric bands as follows:

• Mucosa (echogenic)
• Muscularis mucosa (hypoechoic)
• Submucosa (echogenic)
• Muscularis propria (hypoechoic)
• Serosa (echogenic)

The rectal tumor is demonstrated as a hypoechoic mass with varying mural

invasion (see Image 13). Invasion of the bladder and prostate and adjacent lymph
nodes may be demonstrated. Lymph nodes involved by tumor become spherical
and hypodense rather than oval and hyperdense, as is seen in normal lymph
nodes.

Degree of Confidence: TRUS is limited to lesions located less than 14 cm from

the anus and may not be used for the upper rectum. It may overestimate tumor size
and extent as a result of tumoral inflammatory response. Spread beyond the rectal
wall to the pelvic cavity cannot be detected. TRUS only detects adjacent lymph
nodes.

The sensitivity of TRUS for detection and local staging of rectal tumors (within 14
cm of the anus) is 90-100% (CT is 50-80%), and its specificity is 75% (CT is 33-
80%). TRUS cannot assess the extent of any distant spread beyond its narrow
range.

NUCLEAR MEDICINE Section 8 of 11

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Findings: Nuclear medicine studies have an increasing role in colorectal cancer.

Radioimmunoglobulin scintigraphy uses monoclonal antibody that recognizes

carcinoembryonic antigen or tumor-associated glycoprotein 72 and may be used in
the detection of disease recurrence in the pelvis or extrahepatic abdomen. This
technique is being replaced by positron emission tomography (PET).

PET may detect recurrent or metastatic disease using fluorine-18-

fluorodeoxyglucose (F-18-FDG).

Degree of Confidence: A recent study (Meta, 2001) evaluated the impact of FDG
PET on the management of patients with colorectal carcinoma. They noted a
change in the clinical stage and major management decisions in approximately
40% of patients.

Of the changes in clinical stage in 25 patients, the disease was upstaged in 20

patients (80%) and down-staged in 5 patients (20%). As a result of PET findings,
physicians avoided major surgery in 41% of patients for whom surgery was the
intended treatment.

False Positives/Negatives: False-positive results may occur with FDG in patients

with abscesses from nonspecific inflammatory reactions following radiotherapy or
tracer uptake in bowel, bladder, or ureters.

INTERVENTION Section 9 of 11
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Intervention: Metallic stents may be placed across obstructing carcinomas of the

rectum as a temporary measure to reduce the need for emergency surgery. In
patients unable to undergo surgery or who have unresectable tumors, stents are
used as a palliative procedure. Stent placement is a relatively simple procedure
that rapidly improves the general condition of patients with large bowel obstruction.

In some institutions, intra-arterial chemotherapy via the internal iliac arteries is

performed in patients with unresectable tumors. Similarly, intra-arterial
chemotherapy via the hepatic artery may be used in the management of liver
metastases from colorectal cancer.

Guided liver-directed therapy such as RF ablation and interstitial laser

photocoagulation cause preferential tumor necrosis. RF electrodes or laser fibers
are inserted into the hepatic metastasis under CT or US control followed by tumor
ablation procedures. Promising results, (eg, a 40% 5-year survival), have been
achieved from RF thermal ablation in selected patients with hepatic metastases
from colorectal cancer.

Medical/Legal Pitfalls:

• Failure to recognize the signs and symptoms of rectal cancer

• Failure to appropriately screen patients at various levels of risk

• Failure to detect a carcinoma or polyp (>10 mm) by double-contrast barium

enema or sigmoidoscopy

• Failure to stage the carcinoma correctly using CT or MRI