Pikarsky A, Wexner S, Lebensart P, Efron J, Weiss E, Nogueras J, Reissman P
Department of Colorectal Surgery, The Cleveland Clinic Florida, Fort Lauderdale, Florida 33309, USA.
Am J Surg. 2000 Apr;179(4):261-5. doi: 10.1016/s0002-9610(00)00328-7.
One of the difficulties associated with surgery for rectal villous tumors (RVT) is the finding of invasive adenocarcinoma after transanal excision (TAE) and the possible need for more radical procedures or adjuvant therapy. Improved preoperative evaluation may eliminate this dilemma. The aim of our study was to evaluate the role of transrectal ultrasound (TRUS) in establishing the correct diagnosis of RVT.
All patients with biopsy proven RVT, who were referred for TAE, underwent preoperative TRUS in addition to the routine evaluation. If invasion beyond the submucosa was suspected by TRUS, multiple biopsies were taken before any surgical intervention in order to exclude invasive cancer. If no invasion was noted, biopsies were avoided and a TAE was performed. The final pathology results were compared with both the preoperative diagnosis and TRUS results.
Thirty-five patients (19 female, 16 male; mean age 67.5 years, range 36 to 88) were studied. The mean distance of the distal extent of the lesion above the anal verge was 5.8 cm (1.5 to 6). In 27 patients, the tumor was limited to the submucosa (uT0, uT1) on TRUS and, therefore, TAE was performed. In 26 of 27 patients (96%), pathology examination confirmed the presence of RVT without evidence of malignancy. One patient was found to have invasion of the muscularis propria and required postoperative radiation therapy. In 8 patients (23%), TRUS showed extension beyond the submucosa; 3 of these patients had uT2 lesions, 4 had uT3 tumors, and 1 had perirectal nodes. These 8 patients underwent repeated biopsies with the finding of invasive adenocarcinoma in 7. Two patients underwent abdominoperineal resection, 3 had a low anterior resection, and 3 had a TAE. Final pathology confirmed the preoperative diagnosis of invasive adenocarcinoma in 7 patients. In the 1 patient with a uT2 lesion and negative biopsies, the final diagnosis was RVT with no evidence of malignancy.
Preoperative TRUS provides an accurate diagnosis of RVT. In conjunction with TRUS-directed biopsies, directed management of these tumors could be achieved.
直肠绒毛状肿瘤（RVT）手术的困难之一是经肛门切除（TAE）后发现浸润性腺癌，以及可能需要更根治性的手术或辅助治疗。改进术前评估可能消除这一困境。我们研究的目的是评估经直肠超声（TRUS）在正确诊断RVT中的作用。
所有经活检证实为RVT且因TAE前来就诊的患者，除常规评估外，均接受术前TRUS检查。如果TRUS怀疑肿瘤浸润超过黏膜下层，则在任何手术干预前进行多次活检以排除浸润性癌。如果未发现浸润，则避免活检并进行TAE。将最终病理结果与术前诊断和TRUS结果进行比较。
共研究了35例患者（19例女性，16例男性；平均年龄67.5岁，范围36至88岁）。病变远端距肛缘的平均距离为5.8 cm（1.5至6 cm）。27例患者的肿瘤在TRUS上局限于黏膜下层（uT0、uT1），因此进行了TAE。27例患者中有26例（96%）病理检查证实存在RVT且无恶性证据。1例患者被发现肌层浸润，需要术后放疗。8例患者（23%）TRUS显示病变超出黏膜下层；其中3例为uT2病变，4例为uT3肿瘤，1例有直肠周围淋巴结。这8例患者接受了重复活检，7例发现浸润性腺癌。2例患者接受了腹会阴联合切除术，3例进行了低位前切除术，3例进行了TAE。最终病理证实7例患者术前诊断为浸润性腺癌。1例uT2病变且活检阴性的患者，最终诊断为RVT且无恶性证据。
术前TRUS可准确诊断RVT。结合TRUS引导下的活检，可以实现对这些肿瘤的针对性管理。
