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1 Introduction Rectal Cancer (RC) is a common disease in cancers In recent years, although progress has been made in the diagnosis, treatment, monitoring and screening of cancer, it is still a highly fatal disease worldwide According to Globocan (2018), the incidence of color RC worldwide is more than 1.8 million cases, accounting for 10.2% of the total number of new cancer cases In order to designate RC surgery, which helps predict and benefit patients, the stage assessment problem, especially to determine the extent of tumor invasion and regional lymph node metastasis is very important Today with the development of science and technology, endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) at the sub-frenulum are very meaningful methods Many studies show that EUS is recognized as a good value method with accuracy ranging from 63-96%; in lymph node metastasis determination of RC is about 63-85% compared with computed tomography (65-75%) and MRI (75-85%) In Vietnam, the official scientific literature on the value of EUS for diagnosing the stage of cancer is very small Therefore, we conduct research on the topic: "Research on application of endoscopic ultrasound to contribute to the diagnosis of stage of rectal cancer" with two objectives: Survey of clinical characteristics, endoscopic images, endoscopic ultrasound and histopathology of rectal cancer Evaluation of diagnostic results of endoscopic ultrasound in determining stage of colorectal cancer The urgency of Thesis In recent years, the issue of cancer treatment has made certain progress However, the effectiveness of the treatment method as well as the treatment formula depends on the stage of cancer Staging assessment of the cancer is usually done by combining clinical examination, CT, MRI, rectal ultrasound, and EUS However, colorectal ultrasound has the disadvantage of blind ultrasound, it is difficult to fully assess lesions and especially the narrow evaluation scope, it is not possible to examine rectal tumors at high points CT and MRI have the disadvantage of high cost, sensitivity and specificity in diagnosis of cancer stage only about 60-70% Many studies published it has been shown that EUS is recognized as a good value method with high accuracy, so the study of EUS in assessing the cancer stage is very necessary New contributions of the thesis This is the first thesis in Vietnam that applies EUS in stage diagnosis of rectal cancer The thesis has initially identified: - In the diagnosis of tumor invasion from T1 to T4 level, the general sensitivity, specificity and accuracy of endoscopic ultrasound are 83.3%, 92.8% and 92%, respectively - In the diagnosis of lymph node invasion: The sensitivity, specificity and accuracy of EUS are 73.7%; 78.6% and 77.3% respectively The study also provides data on the characteristics of Rectal Cancer on EUS: Most tumors invade the muscle layer (34.7%) and the serosa (38.7%) 13.3% of tumors invade fat layer and organize it around 52% of tumors were in stage T3 and T4; 34.7% in T2; 34.7% have lymph nodes Layout of the thesis The thesis is presented with 112 pages including: 2-page introduction, 31-page overview, 21-page research objects and methods, 26-page research results, 28-page discussion, 2-page conclusions, 1-page the limitations of the thesis, 1-page recommendations The thesis has 37 tables, charts, including 130 references including 32 Vietnamese documents and 98 English documents CHAPTER DOCUMENT OVERVIEW 1.1 Rectal anatomy 1.2 Rectal Cancer epidemiology 1.2.1 In the world 1.3 Pathogenesis pathology Rectal Cancer 1.4 Clinical manifestations 1.5 Methods of diagnosing Rectal Cancer 1.5.1 Endoscopic Colonoscopy is still an important method for the diagnosis of color Rectal Cancer so far The method has the advantage of being inexpensive, simple technique, but accurately shows the shape, size and position of the tumor at the edge of the anus Through endoscopy combined cell aspiration with small needle to increase diagnostic ability 1.5.2 Intra-rectal ultrasound Intra-rectal ultrasound (IRUS) is a procedure that uses an ultrasound probe to be inserted into the rectum to examine rectal ultrasound and nearby sub-pelvic organs In general, IRUS has similar value to CT in assessing tumors T3 and above, however when evaluating lymph node metastasis is worse than CT IRUS is better than CT to assess surface tumors, while MRI provides a better image of advanced rectal cancer IRUS is comparable to CT in indirect diagnosis of lymph node metastasis 1.5.3 Computerized tomography scan Computerized tomography (CT) allows you to identify tumors, invasive levels, regional lymph node metastases, distal metastases, metastases in the abdominal cavity, diagnose and identify complications such as perforation, intestinal obstruction due to tumor However, CT does not assess the level of cancer invasion by the layers of the rectum wall With small cancers, diagnosing CT will be very difficult The ability to detect lymphadenopathy of CT is lower than rectal ultrasound 1.5.4 Magnetic Resonance Imaging scan An MRI scan is a modern method that allows an accurate assessment of the stage of rectal cancer, including early and recurrent rectal cancer, from which an optimal treatment plan can be planned Numerous studies have shown that EUS and MRI have an additional role in assessing the stage of the tumor 1.5.5 PET/CT 1.5.6 CT scan of the colon lining 1.5.7 Other tests Shooting colon frame CEA test Testing for hidden blood in stool (FOBT-Fecal Occult Blood Test) 1.6 Endoscopic ultrasound in diagnosis of rectal cancer 1.6.1 Endoscopy ultrasoound development history 1.6.2 Endoscopy ultrasound operating principle Today's widely used EUS devices are designed with three types of ultrasound probes: + Radial probes are used to diagnostic ultrasound + Linear ultrasound probe is similar in structure to a Radial probe, the ultrasound beam emanates from the end of the scope in the shape of a fan strip and is in the same plane as the endoscope The transducer, in addition to the function used for diagnostic ultrasound, also provides guidance for cell aspiration and treatment interventions The third type of specially designed transducer looks small like a biopsy pliers (mini probe) is put through the biopsy channel for ultrasound during endoscopy This type of probe has the same structure as the Radial transducer used for diagnostic ultrasound 1.6.3 Rectal imaging on endoscopy ultrasound The rectal wall image on EUS is like the different parts of the digestive tract, which are divided into layers: The first layer of superficial mucosa, which appears as a hyperechoic layer The second layer of deep mucosa, which is hypoechoic The third layer is hyperechoic submucosa The fourth layer is muscularis propria, which appears hypoechoic The fifth layer is adventitial connective tissue, which is hyperechoic 1.6.4 Evaluation rectal cancer on endoscopy ultrasoound Phase evaluation: According to studies of foreign authors, the accuracy of EUS in diagnosing the level of invasion (T - according to TNM classification) of rectal cancer ranges from 80-95%; in identifying lymph node metastases of rectal cancer is about 70-75% Performing a small needle biopsy (FNA) under the EUS guidelines increases the efficiency of diagnosing early T-stage cases and perilymph node suspected around pelvic Lymph nodes: The accuracy of EUS in the diagnosis of lymph nodes is lower than that of stage T because it is difficult to distinguish between inflamed or metastatic lymph nodes as well as identifying small or distant lymph nodes Evaluation of tumor stage after radiotherapy: Studies have shown that the accuracy of EUS in assessing stage T of tumors after radiation therapy is only 50% 1.6.5 Endoscopic ultrasound to detect rectal cancer recurrence Several studies have shown EUS to be very accurate in detecting recurrent cancerous tumors The authors almost agree with the plan to perform rectal follow-up SANS every months for the first years after tumor resection surgery 1.7 Histopathological characteristics and classification of rectal cancer 1.7.1 Histopathological classification 1.7.2 Micro injury 1.7.3 Other forms of cancer of the rectum 1.7.4 Differentiation 1.7.5 Classification of stage rectal cancer according to pathology 1.8 Research situation at home and abroad CHAPTER SUBJECTS AND METHODS OF THE STUDY 2.1 Research subjects Includes 75 patients with rectal adenocarcinoma diagnosed by postoperative pathology, treated at Hospital E from March 2013 to March 2019 2.1.1 Standard selection - Patients with rectal tumors are detected by rectal endoscopy, biopsy makes diagnosis of rectal carcinoma cells - Performing rectal tumor EUS before surgery - All patients underwent radical surgery at the General Surgery Department at E Hospital - Histopathology postoperative result is rectal adenocarcinoma - The patient agrees to participate in the study 2.1.2 Exclusion criteria - Patients not meet the selection criteria - Patients with bleeding disorders - Patients with acute and chronic diseases contraindicated to perform colonoscopy - Patients without surgical treatment - Patients who have previously treated (surgery, radiation, chemicals) - Patients who not perform rectal EUS 2.2 Research Methods 2.2.1 Research Methods - Research cross-sectional description - Sample size: Conduct a convenient sample size 2.2.2 Research facilities - New generation EUS machine: EXERA II CV-180 light source, EUS Radial GF-UE160 probe 3600, EU-ME1 ultrasound source from OLYMPUS (Japan) at E Hospital Hospital's Digestive Center - Siemens CT device with 64 probes at Hospital Imaging Department E - Chemicals, equipment and other means of equipment 2.2.3 Steps to proceed 2.2.3.1 Constructs an outline and data collection form 2.2.3.2 Reach patients and collect general information 2.2.3.3 Clinical research 2.2.3.4 Blood drawn for testing 2.2.3.5 Laboratory techniques 2.2.3.6 Endoscopic technique and rectal endoscopy ultrasound * Prepare the patient * Technical of conduct - Rectal EUS is a special technique of ultrasound In order for the ray of ultrasound to reach the tissue, it is not like an ordinary ultrasound, but the ultrasound probe is covered with a rubber ball before being inserted into the rectum On the endoscopic image when the ultrasound probe is brought to the position where the ultrasound is needed, the rubber ball is fill with water and aspirate air to create a sound conduction environment that touches the transducer with the tissue, parallel the water rubber ball also creates a space for the area to be examined to focus on ultrasound to have the clearest picture - Inserting an ultrasound endoscope into the rectum, observing damage with an endoscope light - Pump the water into the rubber ball, suck the air in the rectum to apply the rubber ball to the wall of the rectum, slowly move the scope in and out and look for damage on both screens: endoscopy and ultrasound * Identify and evaluate results with rectal cancer + The image of the rectum tumor examined is the location, size, depth of penetration, organization around the rectum and surrounding lymph nodes + Image of a normal place: - Thickness of the wall of the rectum
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