MR rectum imaging with ultra sound gel as instrumental contrast media in tubulovillous adenoma
Bacground. Colorectal polyps are frequent and can be found in 10% of adults, most common in elderly with prevalence of 20% in age group of 60. Over 90% cases of cancer are being developed from benign adenomas. Colorectal cancer (CRC) is a significantly large cause of death right after bronchial cancer in males, and breast cancer in women. Therefore, a standpoint was adopted that the removal of polyps as precursor will prevent the development of colorectal area cancer. Polyps can occur as peduncular or sessile. Adenomas are grouped in three subtypes based on histological criteria: tubular, tubulovillous and villous. Villous adenomas are larger than others and show a higher level of dysplasia. The prevalence of adenomas increases with the patient's age. Having in mind that the risk of malign adenoma transformation is 10 years average, and that small lesions have no clinical potential to turn into cancer, their removal would lead to unnecessary complications and additional costs. CRC risk grows both with the size and the number of adenomas. In patients who refuse polypectomy, we can expect cancer development in average of 5 years 4% and in 10 years 14%.
Case report. We present a patient with a years long history of rectal polyp. She has refused any treatment of polyp removal up so far. Due to stool problems, mostly constipation, occasional bleeding and falling out feeling, she has decided to remove the polyp. The polyp has been detected through colonoscopy and described as very risky for polypectomy due to its suspected malign appearance. We did rectum MR on 1.5T Siemens, so that the patient came with clean lumen into which we applied ultra sound gel with huge 60 ml syringe (no needle) simply and pain free with three fillings (total 180 ml of gel). We have concluded that the polyp was of uneven outline and stretched partially along the inner rectum wall without extra rectal infiltration into mesorectal area. After that, we performed endoscopic polypectomy according to peace meal method resection up to real muscular layer after adrenalin undermining. Pathohistological finding which was done in HE technique showed tubulovillous adenoma.
Conclusions. Rectal MR is a new, very reliable method of contemporary radiological imaging that gives better characterization of polyp tissue and of other tumours. It is currently the best imaging modality enabling very accurate evaluation and topographic ratio of tumour growth within the rectum wall and outside the wall, especially compared to mesorectal fascia. In addition, it is a very comfortable procedure without radiation. The application of ultra sound gel as intra luminal rectal contrast agent can distend the lumen and make an excellent contrast of lumen against the rectum wall and thus can better show polyps and tumours.
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Ajaj W, Lauenstein CH, Schneemann H, Knehle C, Herborn UC, Goehde CS, et al. Magnetic resonance colonography without bowel cleansing using oral and rectal stool softeners/fecal cracking/-feasibility study. Eur Radiol 2005; 15: 2079-87.
Winawer SJ, Zauber AG, Ho MN, O'Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The national Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-81.
O'Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, et al. The national polyp study: patient and polyp characteristics associated with high grade dysplasia in colorectal adenomas. Gastroenetrology 1990; 98: 371-9.
Brkic T, Grgic M. Colorectal Carcinoma. Medicus 2006; 15: 89-97.
Blachar A, Sosna J. CT colonography (virtual colonoscopy): technique, indications and performance. Digestion 2007; 76: 34-41.
Roddie M. CT colonography tools advance in clinical use. Diagnostic Imaging Europe 2006; 10: 35-7
Steine S, Stordahl A, Oclocer LK, Laeviw C. Doubl-contrast barium enema versus colonoscopy in the diagnosis of neoplastic disorders: aspects of decision-macing in general practice. Fam Pract 1993; 10: 288-91.
Ott DJ, Gefand DW, WuWC, Kerr RM. Sensitivity of double-contrast barium enema emphasis on polyp detection. AJR Am J Roentgenol 1980; 135: 327-30.
Geenen RW, Hussain SM, Cademartiri F, Poley JW, Siersema PD, Krestin GP. CT and MR colonography: scanning techniques, postprocessing, and emphasis on polyp detection. Radiographics 2004; 24: e18.
Chan TW Kressel HY, Milestone B, Tomachefski J, Schnall M, Rosato E, et al. Rectal carcinoma: staging at MRI imaging with endorectal surface coil. Work in progress. Radiology 1991; 181: 461-7.
Goldman S, Arvidsson H, Norming U, Lagerstedt U, Magnusson I, Frisell J. Transrectal ultrasound and computed topography in preoperative staging of lower rectal carcinoma. Gastrintest Radiol 1991; 16: 259-63.
Klessen C, Rogalla P, Taupitz M. Local staging of rectal cancer: the current role of MRI. Eur Radiol 2007; 17: 379-89.
Maier AG, Kersting-Sommerhoff B, Reeders JW, Judmaier W, Schima W, Annweiler AA, et al. Staging of rectal cancer by double-contrast MR imaging using the rectally administered super paramagnetic iron oxide contrast agent ferristene and IV gadodiamid injection: results of a multicenter phase II trial. J Magn Reson Imaging 2000; 12: 651-60.
Berman L, Israel GM, McCarthy SM, Weinreb JC, Longo WE. Utility of magnetic resonance imaging in anorectal disease. World J Gastroenterol 2007; 13: 3153-8.
Fletcher JG, Busse RF, Riederer SJ, Harigh D, Gluecker T, Harper CM, et al. Magnetic resonance imaging of anatomic ad dynamic defects of the pelvic floor in defecatory disorders. Am J Gastroeneterology 2003; 98: 399-411.
Halligan S. Dynamic pelvic MRI. Imaging 2001; 13: 458-61.