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Endoscopic ultrasound in rectal cancer

Gavin C Harewood, MD
Maurits J Wiersema, MD
Section Editor
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Accurate staging of rectal cancer is essential for selecting patients who can undergo sphincter-preserving surgery and identifying those who could benefit from neoadjuvant therapy. (See "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma".)

Clinical staging is usually accomplished using a combination of physical examination and computed tomography scanning. Other imaging modalities such as magnetic resonance imaging, transrectal and transvaginal ultrasound using rigid instruments, and transrectal endoscopic ultrasound are also frequently used, although their roles are still being determined. (See "Pretreatment local staging evaluation for rectal cancer", section on 'Imaging evaluation'.)

This topic review will summarize experience with endoscopic ultrasound. Discussions on the diagnosis and management of rectal cancer (including other staging methods) are presented separately. (See "Clinical presentation, diagnosis, and staging of colorectal cancer" and "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma" and "Pretreatment local staging evaluation for rectal cancer".)


Transrectal endoscopic ultrasound (EUS) is performed with the patient in the left lateral decubitus position. However, optimal tumor visualization may require repositioning the patient to place the region of interest in the dependent portion of the rectum. This is particularly important when assessing the primary tumor (T) stage of early superficial lesions because the rectum is filled with water, and minimal compression by the balloon is desired to achieve acoustic coupling.

A radial scanning echoendoscope is inserted approximately 30 cm to assess for iliac adenopathy. The wall and periluminal structures are carefully inspected while slowly withdrawing the echoendoscope. If necessary, the linear scanning echoendoscope is also inserted for fine-needle aspiration (FNA) sampling of suspicious extramural lesions (mass/adenopathy) (image 1). The American Society for Gastrointestinal Endoscopy guidelines regarding endoscopic prophylaxis for gastrointestinal procedures do not make a recommendation with regard to antibiotic prophylaxis for EUS-FNA of solid lesions in the lower gastrointestinal tract. Our practice is to give prophylactic ciprofloxacin prior to the FNA (500 mg orally 30 to 60 minutes prior to the procedure or 400 mg IV 30 minutes prior). Oral ciprofloxacin (250 to 500 mg twice daily) is then given for 48 hours after the procedure. However, not all endoscopists routinely use antibiotics in this setting. Conscious sedation is not mandatory, but may be helpful when EUS-guided FNA is performed. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures" and "Overview of procedural sedation for gastrointestinal endoscopy".)

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Literature review current through: Nov 2017. | This topic last updated: Aug 10, 2016.
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  1. Hildebrandt U, Klein T, Feifel G, et al. Endosonography of pararectal lymph nodes. In vitro and in vivo evaluation. Dis Colon Rectum 1990; 33:863.
  2. Tio TL, Coene PP, van Delden OM, Tytgat GN. Colorectal carcinoma: preoperative TNM classification with endosonography. Radiology 1991; 179:165.
  3. Kwok H, Bissett IP, Hill GL. Preoperative staging of rectal cancer. Int J Colorectal Dis 2000; 15:9.
  4. Thaler W, Watzka S, Martin F, et al. Preoperative staging of rectal cancer by endoluminal ultrasound vs. magnetic resonance imaging. Preliminary results of a prospective, comparative study. Dis Colon Rectum 1994; 37:1189.
  5. Meyenberger C, Huch Böni RA, Bertschinger P, et al. Endoscopic ultrasound and endorectal magnetic resonance imaging: a prospective, comparative study for preoperative staging and follow-up of rectal cancer. Endoscopy 1995; 27:469.
  6. Guinet C, Buy JN, Ghossain MA, et al. Comparison of magnetic resonance imaging and computed tomography in the preoperative staging of rectal cancer. Arch Surg 1990; 125:385.
  7. Rifkin MD, Ehrlich SM, Marks G. Staging of rectal carcinoma: prospective comparison of endorectal US and CT. Radiology 1989; 170:319.
  8. Mukae M, Kobayashi K, Sada M, et al. Diagnostic performance of EUS for evaluating the invasion depth of early colorectal cancers. Gastrointest Endosc 2015; 81:682.
  9. Puli SR, Bechtold ML, Reddy JB, et al. How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review. Ann Surg Oncol 2009; 16:254.
  10. Harewood GC, Wiersema MJ. Cost-effectiveness of endoscopic ultrasonography in the evaluation of proximal rectal cancer. Am J Gastroenterol 2002; 97:874.
  11. Harewood GC, Wiersema MJ, Nelson H, et al. A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer. Gastroenterology 2002; 123:24.
  12. Saitoh N, Okui K, Sarashina H, et al. Evaluation of echographic diagnosis of rectal cancer using intrarectal ultrasonic examination. Dis Colon Rectum 1986; 29:234.
  13. Accarpio G, Scopinaro G, Claudiani F, et al. Experience with local rectal cancer excision in light of two recent preoperative diagnostic methods. Dis Colon Rectum 1987; 30:296.
  14. Holdsworth PJ, Johnston D, Chalmers AG, et al. Endoluminal ultrasound and computed tomography in the staging of rectal cancer. Br J Surg 1988; 75:1019.
  15. Dershaw DD, Enker WE, Cohen AM, Sigurdson ER. Transrectal ultrasonography of rectal carcinoma. Cancer 1990; 66:2336.
  16. Jochem RJ, Reading CC, Dozois RR, et al. Endorectal ultrasonographic staging of rectal carcinoma. Mayo Clin Proc 1990; 65:1571.
  17. Katsura Y, Yamada K, Ishizawa T, et al. Endorectal ultrasonography for the assessment of wall invasion and lymph node metastasis in rectal cancer. Dis Colon Rectum 1992; 35:362.
  18. Scialpi M, Andreatta R, Agugiaro S, et al. Rectal carcinoma: preoperative staging and detection of postoperative local recurrence with transrectal and transvaginal ultrasound. Abdom Imaging 1993; 18:381.
  19. Fedyaev EB, Volkova EA, Kuznetsova EE. Transrectal and transvaginal ultrasonography in the preoperative staging of rectal carcinoma. Eur J Radiol 1995; 20:35.
  20. Waizer A, Powsner E, Russo I, et al. Prospective comparative study of magnetic resonance imaging versus transrectal ultrasound for preoperative staging and follow-up of rectal cancer. Preliminary report. Dis Colon Rectum 1991; 34:1068.
  21. Blomqvist L, Machado M, Rubio C, et al. Rectal tumour staging: MR imaging using pelvic phased-array and endorectal coils vs endoscopic ultrasonography. Eur Radiol 2000; 10:653.
  22. Lindmark G, Elvin A, Påhlman L, Glimelius B. The value of endosonography in preoperative staging of rectal cancer. Int J Colorectal Dis 1992; 7:162.
  23. Hawes RH. New staging techniques. Endoscopic ultrasound. Cancer 1993; 71:4207.
  24. Mehta S, Johnson RJ, Schofield PF. Staging of colorectal cancer. Clin Radiol 1994; 49:515.
  25. Kim HJ, Wong WD. Role of endorectal ultrasound in the conservative management of rectal cancers. Semin Surg Oncol 2000; 19:358.
  26. Herzog U, von Flüe M, Tondelli P, Schuppisser JP. How accurate is endorectal ultrasound in the preoperative staging of rectal cancer? Dis Colon Rectum 1993; 36:127.
  27. Boyce GA, Sivak MV Jr, Lavery IC, et al. Endoscopic ultrasound in the pre-operative staging of rectal carcinoma. Gastrointest Endosc 1992; 38:468.
  28. Beynon J, Mortensen NJ, Foy DM, et al. Preoperative assessment of mesorectal lymph node involvement in rectal cancer. Br J Surg 1989; 76:276.
  29. Orrom WJ, Wong WD, Rothenberger DA, et al. Endorectal ultrasound in the preoperative staging of rectal tumors. A learning experience. Dis Colon Rectum 1990; 33:654.
  30. Glaser F, Schlag P, Herfarth C. Endorectal ultrasonography for the assessment of invasion of rectal tumours and lymph node involvement. Br J Surg 1990; 77:883.
  31. Milsom JW, Graffner H. Intrarectal ultrasonography in rectal cancer staging and in the evaluation of pelvic disease. Clinical uses of intrarectal ultrasound. Ann Surg 1990; 212:602.
  32. Hulsmans FJ, Tio TL, Fockens P, et al. Assessment of tumor infiltration depth in rectal cancer with transrectal sonography: caution is necessary. Radiology 1994; 190:715.
  33. Marusch F, Ptok H, Sahm M, et al. Endorectal ultrasound in rectal carcinoma--do the literature results really correspond to the realities of routine clinical care? Endoscopy 2011; 43:425.
  34. Ahuja NK, Sauer BG, Wang AY, et al. Performance of endoscopic ultrasound in staging rectal adenocarcinoma appropriate for primary surgical resection. Clin Gastroenterol Hepatol 2015; 13:339.
  35. Dixon AK, Fry IK, Morson BC, et al. Pre-operative computed tomography of carcinoma of the rectum. Br J Radiol 1981; 54:655.
  36. Puli SR, Reddy JB, Bechtold ML, et al. Accuracy of endoscopic ultrasound to diagnose nodal invasion by rectal cancers: a meta-analysis and systematic review. Ann Surg Oncol 2009; 16:1255.
  37. Park HH, Nguyen PT, Tran Q, et al. Endoscopic ultrasound-guided fine needle aspiration in the staging of rectal cancer (abstract). Gastrointest Endosc 2000; 51:AB171.
  38. Wiersema MJ, Kochman ML, Cramer HM, et al. Endosonography-guided real-time fine-needle aspiration biopsy. Gastrointest Endosc 1994; 40:700.
  39. Chang KJ, Nguyen P, Erickson RA, et al. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc 1997; 45:387.
  40. Rodriguez J, Kasberg C, Nipper M, et al. CT-guided needle biopsy of the pancreas: a retrospective analysis of diagnostic accuracy. Am J Gastroenterol 1992; 87:1610.
  41. Gress FG, Savides TJ, Sandler A, et al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study. Ann Intern Med 1997; 127:604.
  42. Wiersema MJ, Vilmann P, Giovannini M, et al. Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997; 112:1087.
  43. Giovannini M, Seitz JF, Monges G, et al. Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 1995; 27:171.
  44. Williams DB, Sahai AV, Aabakken L, et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut 1999; 44:720.
  45. Catalano MF, Alcocer E, Chak A, et al. Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS. Gastrointest Endosc 1999; 50:352.
  46. Giovannini M, Monges G, Seitz JF, et al. Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound-guided biopsy. Endoscopy 1999; 31:536.
  47. Gleeson FC, Kipp BR, Voss JS, et al. Endoscopic ultrasound fine-needle aspiration cytology mutation profiling using targeted next-generation sequencing: personalized care for rectal cancer. Am J Clin Pathol 2015; 143:879.
  48. Harewood GC. Assessment of clinical impact of endoscopic ultrasound on rectal cancer. Am J Gastroenterol 2004; 99:623.
  49. Frasson M, Garcia-Granero E, Roda D, et al. Preoperative chemoradiation may not always be needed for patients with T3 and T2N+ rectal cancer. Cancer 2011; 117:3118.
  50. Carmody BJ, Otchy DP. Learning curve of transrectal ultrasound. Dis Colon Rectum 2000; 43:193.
  51. Mascagni D, Corbellini L, Urciuoli P, Di Matteo G. Endoluminal ultrasound for early detection of local recurrence of rectal cancer. Br J Surg 1989; 76:1176.
  52. Ramirez JM, Mortensen NJ, Takeuchi N, Humphreys MM. Endoluminal ultrasonography in the follow-up of patients with rectal cancer. Br J Surg 1994; 81:692.
  53. Novell F, Pascual S, Viella P, Trias M. Endorectal ultrasonography in the follow-up of rectal cancer. Is it a better way to detect early local recurrence? Int J Colorectal Dis 1997; 12:78.
  54. Maor Y, Nadler M, Barshack I, et al. Endoscopic ultrasound staging of rectal cancer: diagnostic value before and following chemoradiation. J Gastroenterol Hepatol 2006; 21:454.
  55. Romagnuolo J, Parent J, Vuong T, et al. Predicting residual rectal adenocarcinoma in the surgical specimen after preoperative brachytherapy with endoscopic ultrasound. Can J Gastroenterol 2004; 18:435.
  56. Vanagunas A, Lin DE, Stryker SJ. Accuracy of endoscopic ultrasound for restaging rectal cancer following neoadjuvant chemoradiation therapy. Am J Gastroenterol 2004; 99:109.
  57. Pastor C, Subtil JC, Sola J, et al. Accuracy of endoscopic ultrasound to assess tumor response after neoadjuvant treatment in rectal cancer: can we trust the findings? Dis Colon Rectum 2011; 54:1141.
  58. de Jong EA, ten Berge JC, Dwarkasing RS, et al. The accuracy of MRI, endorectal ultrasonography, and computed tomography in predicting the response of locally advanced rectal cancer after preoperative therapy: A metaanalysis. Surgery 2016; 159:688.
  59. Rotondano G, Esposito P, Pellecchia L, et al. Early detection of locally recurrent rectal cancer by endosonography. Br J Radiol 1997; 70:567.
  60. Hünerbein M, Totkas S, Moesta KT, et al. The role of transrectal ultrasound-guided biopsy in the postoperative follow-up of patients with rectal cancer. Surgery 2001; 129:164.
  61. Löhnert MS, Doniec JM, Henne-Bruns D. Effectiveness of endoluminal sonography in the identification of occult local rectal cancer recurrences. Dis Colon Rectum 2000; 43:483.