Abstract
This case report describes the novel use of ultrasound-guided MRI-fusion biopsy to sample an extraluminal perirectal mass. This is a 64-year-old man with a history of pT3N2b mucinous adenocarcinoma of the right colon with metastatic disease to the mesocolic lymph nodes. Two years after initial resection he was found on restaging CT to have a mass measuring ∼4.0 × 4.8 cm superior to the seminal vesicles. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a moderately FDG avid soft tissue mass interposed between the prostate and the rectum. Multiparametric MRI revealed a 6.2 × 4.6 × 2.8 cm heterogeneous lobulated T2 hyperintense mass with enhancement just superior to the seminal vesicles. This mass was unable to be viewed using sigmoidoscopy. Using UroNAV technology, we were able to biopsy the mass in the clinic setting. Biopsy was confirmed as recurrent mucinous adenocarcinoma.
Keywords: image-guided therapy, UroNAV, perirectal mass
Introduction
MRI-fusion biopsy of the prostate is rapidly becoming integrated into urologic practice as a more precise method to target lesions that may be difficult with standard biopsy techniques.1 Diffusion of MRI-fusion biopsy innovation has entered into other fields such as breast and liver cancer.2–5 Most rectal biopsies can be directly viewed and sampled on our sigmoidoscopy; however, some lesions are extraluminal and out of endoscopic view and reach. This case report describes the novel use of ultrasound (US)-guided MRI-fusion biopsy to sample an extraluminal perirectal mass.
Case
A 64-year-old man with a history of pT3N2bM0 mucinous adenocarcinoma of the right colon with metastatic disease to the mesocolic lymph nodes. After initial resection, 2 years later he was found on restaging CT to have a mass measuring ∼4.0 × 4.8 cm superior to the seminal vesicles. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed a moderately FDG avid soft tissue mass interposed between the prostate and the rectum. Multiparametric MRI (mpMRI) revealed a 6.2 × 4.6 × 2.8 cm heterogeneous lobulated T2 hyperintense mass with enhancement just superior to the seminal vesicles. This mass was unable to be viewed using sigmoidoscopy.
Methods
mpMRI was processed using DynaCAD software for use with the UroNAV platform (Invivo Phillips, Gainesville, FL). The prostate gland was segmented as a reference point. The tumor region of interest (ROI) was marked on axial T2-weighted imaging. The study was then imported to the UroNAV. The BK 3000 (BK Medical, Peabody, MA) was used with a 11–3 MHz biplanar transrectal probe. The patient had completed a rectal swab for quinolone resistance and was given Ciprofloxacin 500 mg for 72 hours, starting 1 day before biopsy. A Fleet's enema was given prior and intramuscular Amikacin at the time of biopsy for augmented antibiotic prophylaxis. After a local block with 1% lidocaine/0.25% Marcaine, a US sweep was completed of the prostate. Segmentation of the prostate was done as a reference point in sagittal and axial to optimize coregistration of US and MRI with smoothing adjustment. The US was then aligned with the MR to adjust for axis rotation using blending and the prostate as a reference. Elastic deformation was applied to warp the MRI to the match the US. Interprocedure alignment was done to minimize left right offset and to maintain the MRI profile. The target was brought over the ROI and an 18G, 25 cm biopsy gun (Cook Medical) was used to obtain four samples at various locations within the ROI; the biopsy needle was dipped in formalin between samples to sterilize the needle tip. There was no rectal hemorrhage or vasovagal episode. Total procedure time took 7 minutes.
Results
The patient underwent a UroNav targeted biopsy. Figures 1–3 show the perirectal mass. A total of six cores were obtained. All six cores hit the tumor. Pathology analysis returned as recurrent mucinous adenocarcinoma. Patient was discussed at tumor board and will undergo chemoradiation for treatment.
FIG. 1.
MRI images of posterior rectal mass.
FIG. 2.
PET images of perirectal mass.
FIG. 3.
DynaCAD editing of perirectal mass, UroNav MRI targeted perirectal mass biopsy.
Discussion
MRI-fusion technology has rapidly permeated the field of urology for targeted biopsy of the prostate. This technique has improved the accuracy, lowered the number of cores needed, and increased diagnostic confidence. In this report, we applied this method to sample an extraluminal colorectal cancer. Although most colorectal masses can be viewed and biopsied with colonoscopy, some masses are extraluminal and outside the purview of endoscopic methods. Biopsy of these rare lesions can be challenging, typically requiring a CT-guided transgluteal interventional radiology approach if a window is available or a more invasive laparoscopic approach. Transrectal MRI-fusion biopsy can be applied to sample any lesion that is within reach of a transrectal probe and a 25 cm needle; depending on body habitus/gluteal corpulence this translates to any target about 4 cm cephalad to the seminal vesicles within a 7 cm radius (end fire) or 11 cm (side fire), including perirectal or pelvic tumors and lymph nodes (Figure 4). An added advantage of using MRI-fusion biopsy over CT-guided biopsy is the ability to perform these procedures in the clinic setting rather than an operating room. Also, since only local anesthetizing agents are used, it can diminish the need for general anesthesia and may be safer for patients with comorbidities.
FIG. 4.
Additional length from biopsy probe.
Another issue with any biopsy for malignancy is the concern for seeding along the biopsy tract. There is no literature regarding rectal biopsy for mucinous adenocarcinoma seeding rates, but the studies from transrectal prostate biopsy and breast biopsy for mucinous adenocarcinoma in the breast suggest low rates of seeding from this procedure. In regard to prostate cancer adenocarcinoma, rates of seeding from transrectal biopsy range from 0.15% to 1%, with the higher rates in the past and decreasing rates in the present.6,7 When looking at biopsies for mucinous adenocarcinoma for the breast, they concluded that there was little risk of seeding from this type of carcinoma along the needle tract.8 This suggests that rectal biopsy for mucinous adenocarcinoma would similarly have minimal risk of tumor seeding.
This case report demonstrates an interesting case of applying a urologic technique in the clinic for another specialty. This demonstrates how our procedures can be used to expand the diagnostic capabilities of the colorectal surgeon for these uncommon lesions.
Abbreviations Used
- CT
computed tomography
- FDG
fluorodeoxyglucose
- MRI
magnetic resonance imaging
- mpMRI
multiparametric MRI
- PET
positron emission tomography
- ROI
region of interest
- US
ultrasound
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Cite this article as: Li V, Mclemore E, Attaluri V, Parker R, Finley DS (2020) Transrectal ultrasound MRI-fusion biopsy of perirectal mass, Journal of Endourology Case Reports 6:4, 366–369, DOI: 10.1089/cren.2020.0016.
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