British Journal of Radiology (2007) 80, e241-e242
© 2007 British Institute of Radiology
doi: 10.1259/bjr/23634915
Recurrent rectal tumour: localization using CT-guided percutaneous 'breast coil' placement prior to surgery
P A Vlachou, MRCS
R Sinha, FRCR
and
R Verma, MRCP, FRCR
Department of Radiology, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
Correspondence: Dr Paraskevi A Vlachou, Department of Radiology, Leicester Royal Infirmary, Leicester LE1 5WW, UK. E-mail: pvlachou{at}hotmail.com
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Abstract
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A 58-year-old man presented with rectal tumour recurrence 5 years following abdomino-perineal resection for rectal cancer. As the recurrent lesion was small and surrounded by fibrotic tissue, it was felt necessary to localize the lesion prior to surgery. We describe the use of percutaneous CT-guided breast localization coil placement using a transgluteal approach for the pre-operative localization of such lesions in order to facilitate surgical removal.
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Introduction
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A 58-year-old male patient underwent an abdominoperineal resection for rectal cancer (Duke's A), which was followed by combination chemotherapy and radiotherapy. The patient re-presented with a history of perineal pain, vague urinary symptoms and fatigue 5 years after the initial surgery. A clinical examination performed at presentation was unremarkable. A CT scan of the abdomen and pelvis was performed with intravenous contrast administration. On the CT examination a well-defined perineal mass, measuring approximately 9 mm in diameter, was seen adjacent to the left inferior gluteal artery (Figure 1
). A small amount of fibrotic stranding was seen adjacent to the mass. To further assess the nature of this lesion in view of the patient's previous history of rectal cancer, a positron emission tomography (PET) scan was performed. The PET scan showed uptake of isotope within the soft tissue mass seen on the CT examination (Figure 2). Based on the imaging findings, a presumptive diagnosis of recurrent rectal tumour was made.
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Figure 2. Positron emission tomography(PET) image demonstrates uptake in the soft tissue (arrow) mass demonstrated on the CT examination.
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Because the lesion was very small, with surrounding fibrosis and in close proximity to the gluteal artery, radiological localization was requested to assist in the surgical excision. Localization of the lesion was performed using a transgluteal approach through the greater sciatic foramen under CT guidance. Following informed written consent, the patient was placed in a prone position and, under aseptic technique, a 19.5 gauge introducer needle (Breast Lesion Localization Coil Set; William Cook Europe), was placed within the soft tissue mass and 10 ml of 1% lignocaine introduced. After removal of the internal stylette, two 4 mm breast localization coils were placed in the mass through the introducer needle using the supplied pusher (Figure 3). No sedation was required for the procedure. Further images were obtained at the end of the procedure to confirm the position of the coils. We did not encounter any problems during the procedure but potential complications include injury to the sciatic nerve, haemorrhage and pseudoaneurysm formation of the inferior gluteal artery.
At laparotomy, the contained coils were identified by palpation and the surrounding tissue was excised. At histological examination the coils were found embedded in the excised segment containing the recurrent tumour. A nodule of fibrofatty tissue (4 mm) was found containing clusters of cells with irregular nuclei. These stained for cytokeratin 20 (CK 20) and carcinoembryonic antigen (CEA) on immunohistochemistry and were consistent with being cells from colorectal carcinoma, showing changes secondary to radiotherapy/chemotherapy (Figure 4).
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Figure 4. Histological specimen of fibrofatty tissue containing small clusters of epithelial cells with irregular nuclei. Using immunohistochemistry, these cells stained for CEA and CK 20, in keeping with recurrent colorectal carcinoma.
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Discussion
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Local recurrence or a residual mass after chemoradiotherapy and surgery is a recognized complication of rectal tumours. These masses can often be small in size and located in relatively inaccessible areas of the pelvis or perineum. Imaging can be of help in localizing such residual or recurrent lesions prior to surgery. Accurate localization of small lesions can be of help to the surgeon performing the excision. Pre-operative insertion of breast wires has been previously described for localization of occult breast lesions [1]. CT-guided localization using methylene blue has also been described; however, this technique has mainly been described in pulmonary tumour localization. [2]. Recently, the use of a Kopans hookwire for pre-operative localization of an appendicolith has been reported [3].
In this particular case a breast coil rather than a hookwire was used for localization. The authors feel that this particular technique can be useful in two settings. First, if the surgical excision is planned in the supine position and localization is carried out in the prone position then a percutaneously extruding hookwire can be cumbersome and also uncomfortable for the patient. Second, if surgery is not planned immediately after localization then a hookwire placement is again unsuitable as the extruding wire may be uncomfortable for the patient. In these specific scenarios a breast coil may be used, which can be left embedded in situ within the localized mass. In a previously reported case using a hookwire [3], the patient was operated on in the prone position and immediately after localization.
In summary, we describe an alternative method for the localization of small abdominopelvic masses using breast coils that can be left in situ. Accurate localization of such small tumours may also help to facilitate minimally invasive laparoscopic excision techniques. This method of localization also has the potential to be used for localizing lesions prior to radiotherapy planning.
Received for publication March 12, 2006.
Revision received July 25, 2006.
Accepted for publication August 9, 2006.
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References
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- Kopans DB, DeLuca S. A modified needle-hookwire technique to simplify preoperative localization of occult breast lesions. Radiology 1980;134:781[Abstract/Free Full Text]
- Wicky S, Mayor B, Cuttat JF, Schnyder P. CT-guided localization of pulmonary nodules with methylene blue injection for thoracoscopic resections. Chest 1994;106:1326–8.[Medline]
- Lossef SV. CT-guided Kopans hookwire placement for preoperative localization of an appendicolith. AJR Am J Roentgenol 2005;185:81–3.[Abstract/Free Full Text]
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Abstract
Introduction
