Rectal Cancer Staging

ERUS criteria to determine the depth of tumour invasion, based on the classification proposed by Hildebrandt and Feifel [3], are as follows: (a) uT0 (benign lesion): the mucosal layer is expanded but the third hyperechoic submucosal layer remains intact around the entire breadth of the tumour; (b) uT1 (submucosal cancer): the hyperechoic submucosal layer is

Fig. 8a, b. Normal ultrasound anatomy of the anal sphincter in 2D (a) and 3D (b)

Fig. 8a, b. Normal ultrasound anatomy of the anal sphincter in 2D (a) and 3D (b)

irregular or interrupted consistent with tumour invasion. The fourth hypoechoic layer of the muscolaris propria is intact; (c) uT2: a distinct break is seen in the submucosal layer and the muscolaris propria is thickened. The surrounding hyperechoic layer corresponding to the serosa or perirectal fat remains intact; (d) uT3: disruption of the hyperechoic layer corresponding to the submucosa, thickening of the hypoechoic layer representing the muscolaris propria and presence of irregularities of the outer hyper-echoic layer which corresponds to the serosa or perirectal fat interface; and (e) uT4: extensive local invasion with loss of the normal hyperechoic interface between tumour and the adjacent organ or invasion of the serosa in tumours above the peritoneal reflection.

Undetectable or benign appearing lymph nodes are classified as uN0. Pathologic lymph nodes are defined as circular or slightly oval-shaped structures, often with an irregular border, with an echogenicity similar to the tumour and most commonly found adjacent or in the mesorectum proximal to the primary tumour. Malignant appearing lymph nodes are classified as: (a) uN1: <3 malignant lymph nodes identified, and (b) uN2: >3 malignant lymph nodes identified.

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