Stage uT2 Invasion of the Muscular Layer

Sonographic diagnosis of tumour invasion of the muscolaris propria is based on thickening of this layer (Fig. 13). The muscolaris propria is represented by a thin hypoechoic layer adjacent to the hypere-choic submucosal interface. As the tumour is also hypoechoic, early muscular invasion is difficult to

Fig. 13a, b. uT2 rectal tumour in 2D (a) and 3D (b)

Fig. 14a, b. uT3 rectal tumour in 2D (a) and 3D (b)

Fig. 14a, b. uT3 rectal tumour in 2D (a) and 3D (b)

detect. The surrounding hyperechoic layer corresponding to the perirectal fat interface remains intact. Lymph node metastases occur in approximately 15-20% of patients with T2 tumours. ERUS is important to distinguish uT2 and uTl lesions, because local therapy is not routinely recommended for uT2 rectal lesions.

Overstaging is a particular problem with T2 tumours. Among the interpretative errors, severe inflammatory infiltrate underlying a tumour, which is sonographically indistinguishable from malignant tissue, can prohibit accurate evaluation of tumour invasion and appears to cause inevitable error. Understaging, on the other hand, may be caused by a failure to detect microscopic cancer infiltration owing to the limits of resolution of the equipment.

cumstances the study may be incomplete and the presence of enlarged lymph nodes may not be ascertained with accuracy because nodes are often located proximal to the tumour. The incidence of regional lymph node metastases in uT3 tumours is approximately 30-50%.

The recognition of perirectal fat invasion is an important determination to select appropriate patients for pre-operative combined chemotherapy and radiation therapy followed by surgery. One of the most important drawbacks in endosonographic staging is the distinction between T2 tumour invading most of the muscolaris propria and T3 tumour which slightly invades the perirectal fat. Indeed most errors are understaging of small pT3 tumours or overstag-ing of pT2 tumours [15].

Fig. 15. Three-dimensional ERUS showing a tumour that narrows the rectal lumen

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