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The Use of Transrectal Ultrasound in the Detection and Evaluation of Local Pelvic Recurrences after a Radical Urological Pelvic Operation
0022-5347 /90/1443-0?11$02.00/0 THE ,JOURI'-JAL OF UROLOGY
Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC,
THE USE OF TRANSRECTAL ULTRASOUND IN THE DETECTION AND EVALUATION OF LOCAL PELVIC RECURRENCES AFTER A RADICAL UROLOGICAL PELVIC OPERATION RAUL 0. PARRA, RICHARD M. WOLF
AND
ROBERT P. HUBEN
From the St. Louis University Medical Center, St. Louis, Missouri, and Roswell Park Memorial Institute, Buffalo, New York
ABSTRACT
Transrectal ultrasound was performed in 20 patients with suspected local pelvic recurrence after a radical pelvic operation: 9 had undergone radical prostatectomy and 11 had undergone radical cystoprostatectomy. Transrectal sonography verified the presence of recurrence in 19 of 20 patients (95%) and this was confirmed by biopsy of the visualized lesions. Analysis of the sonographic echo patterns encountered revealed that in 14 of 19 recurrent neoplasms (71.5%) the echogenic pattern was hypoechoic. In the remaining 6 patients (31.5%) the echo pattern was isoechoic. No hyperechoic lesions were noted. Based upon our findings and because of the low costs compared to other diagnostic modalities transrectal ultrasound represents an ideal technique to compliment the digital rectal examination in evaluation of patients suspected of harboring a local pelvic recurrence after a radical pelvic operation. (J. Ural., 144: 707-709, 1990) Patients who undergo a radical pelvic operation with the intent of cure of either prostate or bladder cancer require careful periodic monitoring for the possibility of tumor recurrence. The presence of local recurrence sometimes is the only indication of treatment failure, whereas distant metastatic disease is readily recognized by the use of conventional radiological studies, radionuclide scans or tumor markers. An inexpensive and accurate means to image local recurrences has not been available. Recently, the use of transrectal ultrasound has gained recognition in the diagnosis and staging of prostatic carcinomao 1 - 6 We applied this modality in 20 consecutive patients with a suspected local pelvic recurrence after radical prostatectomy or radical cystectomy and we report our experience. MATERIALS AND METHODS
A total of 20 men with suspected local pelvic recurrences underwent evaluation with transrectal ultrasound between July 1982 and March 1989. Patient age ranged from 43 to 60 years (mean age 5205 years)" Eleven patients had undergone radical cystoprostatectomy for invasive transitional cell carcinoma of the bladder (pathological stage pT2 in 6, pT3a in 3 and pT3b in 2), while 9 had undergone radical prostatectomy (pathological stage A2 in 1, B2 in 4 and C in 4). Pathological stage was based on the histological evaluation of the surgical specimen. An abnormality detected during digital rectal examination was the most common form of presentation" An abnormal digital rectal examination was defined as any induration or mass in the lower pelvis during a routine physical examination" Such findings were present in 7 of 9 and 8 of 11 patients after radical prostatectomy and cystectomy, respectively. In 2 of the men after radical prostatectomy the digital rectal examination was reported as normal but elevated levels of serum prostatic specific antigen (PSA) in the presence of a normal bone scan led to further investigation. The levels in these men were 28.6 and 31 ng./dl. individually. In only 2 other patients were concomitant PSA level determinations done and in both no significant detectable levels were present. Of the 3 patients who had a normal digital rectal examination after radical cystoprostatectomy 1 presented with lower abdominal pain, and 2 presented with deterioration of the clinical status and no evidence of distant metastatic disease on further evaluation. Transrectal ultrasound examination of the pelvis was performed with an Aloka-SSD-501 chair-mounted model with a 3.5 MHz. axial Accepted for publication March 28, 1990.
transducer in 8 patients during our early experience. A BruelKjaer model 1849 or a Kretz model 310 device, both with axial and sagittal 7.5 MHz. high frequency transducers, respectively, was used in the latter 11 patients. Selected views were recorded with either self-developing film or with images obtained from a Mitsubishi thermal printer. A study was considered positive if a mass was detected and confirmed on real-time scanning, so as not to be confused with loops of bowel present in the postoperative pelvis. Lesions were classified as hypoechoic if the sonographic appearance was less echogenic than the surrounding tissues, isoechoic if the sonographic features were not clearly differentiated from surrounding structures and hyperechoic if the lesion was significantly more echogenic than adjacent tissues. Computerized tomography (CT) was only available in 4 post-radical cystectomy patients and, therefore, no meaningful comparison between the 2 modalities could be done. All suspected lesions were biopsied transrectally after appropriate antibiotic coverage. In the group studied with the chair-mounted equipment no ultrasound guided biopsy capability was available, so that these 8 patients underwent standard digitally guided needle biopsies of the masses with a 14 gauge Tru-Cut* needle" The remaining 11 patients underwent ultrasound guided biopsies with a Biopty gun.t In all instances sufficient tissue adequate for histopathological diagnosis was obtained. RESULTS
Transrectal ultrasound visualized an abnormality in all 20 patients, 19 of whom were confirmed to have local tumor recurrence by needle biopsy. An analysis of the echogenic patterns obtained revealed that in the majority of patients (14 of 19 recurrences, or 71.5%) the echogenic pattern was hypoechoic (7 in the post-radical prostatectomy and 7 in the postradical cystectomy groups, see figure). In the remaining 6 patients (31.5%) the pattern was interpreted as isoechoic (2 after radical prostatectomy and 4 after radical cystectomy). The only patient with a false positive examination had an isoechoic mixed lesion that was biopsied under ultrasound guidance and was consistent with scar tissue. No hyperechoic lesions were found. The histopathological origin and characteristics of the tumor recurrences had no bearing or correlation in regard to the echogenicity of the lesions as demonstrated on * Travenol Laboratories, Inc., Deerfield, Illinois.
t Bard Urological, Murray Hill, New Jersey.
708
PARRA, WOLF AND HUBEN
Transverse scan of small nonpalpable recurrence after radical prostatectomy shows typical hypoechoic anterior location (3.5 MHz.). transrectal ultrasound. The size of the recurrences detected by ultrasonography ranged from 2.5 to 7 cm. with a mean of 4. 7 cm. Unfortunately, in this study no sonographic volume determinations of the lesions were performed routinely, which in retrospect would have given a more precise measurement. The recurrences were consistently either in the anterior or anterolateral location in relation to the rectum as seen by endorectal sonography. Transrectal ultrasound examinations were all tolerated with minimal complaints from the patients and no biopsy-related complications were encountered, except for discomfort in patients who underwent digitally guided Tru-Cut needle biopsies. A direct comparison between the sonographic images and the CT scan in the 4 patients in whom both studies were done simultaneously showed that transrectal ultrasound was able to delineate the recurrent lesions more readily than CT. DISCUSSION
The incidence of local pelvic recurrences after radical prostatectomy and radical cystoprostatectomy reported in the literature is 10% in the former group 7 • 8 and ranges between 9 and 28% in the latter group depending upon whether preoperative radiation therapy was used. 9 Most commonly, such recurrences are suspected based on deterioration of the clinical status or a palpable abnormality during digital rectal examination. However, digital rectal examination is a subjective examination that cannot readily differentiate between malignant and benign tissues. Therefore, consistency of information between examiners can vary widely, thus, making reliable documentation difficult. CT of the pelvis often is used in the preoperative staging of individuals with prostate and bladder cancer with sometimes conflicting results. 10 Lee and associates reported on the use of this modality in the evaluation of patients after radical cystoprostatectomy. They were able to define masses consistent with recurrent neoplasms in 7 of 8 patients. 11 The lesions found were large in volume and, therefore, easily detectable. CT lacks sufficient sensitivity to detect lesions smaller than 2 cm. The technique also is expensive and has the risk of exposure of the patient to radiation and contrast material. Furthermore, when surgical hemostatic clips are used images may be hindered by bothersome artifacts. Even though only 4 of our patients also underwent concomitant CT evaluation ultrasound proved to be more valuable, since CT was unable to define these tumors easily. This finding may be due to the fact that most of the recurrences documented were small in size and lower down in the pelvis, thus, they were easier to detect by ultrasound. However, the numbers available are too small to
make a true comparison between both modalities. Magnetic resonance imaging (MRI) of the pelvis is in a state of evolution 12 and, although it holds great promise, its use in the postoperative patient may be limited, especially when metal clips are present. In addition, availability and costs also must be considered. Transrectal ultrasound has extended our capability to examine the prostate gland. 1- 6 Therefore, this technique lends itself to be applied readily to the study of the postoperative pelvis. In all of our patients we were able to visualize an abnormality clearly, 19 of which represented a tumor recurrence based upon the biopsy material. All patients studied had clinical indications for performance of transrectal ultrasonography based either on abnormalities discovered during digital rectal examination or other clinical conditions attesting to recurrent disease. The echogenicity is predominantly hypoechoic as seen in 71.5% of the cases, which had been noted previously in our early experience. 13 The sensitivity of transrectal ultrasound over digital rectal examination did not prove to be far superior, since 15 of the 20 men also had a suspicious digital rectal examination. Presently, transrectal ultrasound is unable to differentiate clearly a scar from malignant tissue. However, we believe that transrectal ultrasound adds the ability to measure objectively and to document tumor size and location, which can be helpful in the followup of future treatment response or progression of the disease. In addition, ultrasound-guided biopsies can be performed more accurately with minimal discomfort and morbidity. In conclusion, transrectal ultrasound represents a useful imaging modality that can be used adjunctively with digital rectal examination in the documentation of local pelvic recurrences. REFERENCES
1. Resnick, M. I., Willard, J. W. and Boyce, W. M.: Transrectal
ultrasonography in the evaluation of patients with prostatic carcinoma. J. Urol., 124: 482, 1980. 2. Spirnack, J. P. and Resnick, M. I.: Ultrasound and the evaluation of the prostate. In: New Techniques in Urology. Edited by R. W. deVere White and J.M. Palmer. Mt. Kisco, New York: Futura Publishing Co., chapt. 16, pp. 251-268, 1984. 3. Lee, F., Gray, J. M., McLeary, R. D., Meadows, T. R., Kumasaka, G. H., Borkaza, G. S., Straub, W. H., Lee, F., Jr., Solomon, M. H., McHugh, T. A. and Wolf, R. M.: Transrectal ultrasound in the diagnosis of prostate cancer: location, echogenicity, histopathology, and staging. Prostate, 7: 117, 1985. 4. Lee, F., Gray, J. M., McLeary, R. D., Lee, F., Jr., McHugh, T. A., Solomon, M. M., Kumasaka, G. H., Staub, W. H., Borlaza, G. S. and Murphy, G. P.: Prostatic evaluation by transrectal sonography: criteria for diagnosis of early carcinoma. Radiology, 158: 92, 1986.
5. Rifkin, M. D., Friedland, G. W. and Shortliffe, L.: Prostatic evaluation by transrectal endosonography: detection of carcinoma. Radiology, 158: 85, 1986. 6. Waterhouse, R. L. and Resnick, M. I.: The use of transrectal prostatic ultrasonography in the evaluation of patients with prostatic carcinoma. J. Urol., 141: 233, 1989. 7. Walsh, P. C.: Radical prostatectomy, preservation of sexual function, cancer control. The controversy. Urol. Clin. N. Amer., 14: 663, 1987. 8. Robey, L. E. and Schellhammer, P. F.: Local failure after definitive therapy for prostatic cancer. J. Urol., 137: 613, 1987.
9. Crawford, E. D., Das, S. and Smith, J. A., Jr.: Preoperative radiation therapy in the treatment of bladder cancer. Urol. Clin. N. Amer., 14: 781, 1987. 10. Sawczuk, I. S., deVere White, R., Gold, R. P. and Olsson, C. A.: Sensitivity of computed tomography in evaluation of pelvic lymph node metastasis from carcinoma of bladder and prostate. Urology, 21: 81, 1983. 11. Lee, J. K., McClennan, B. L., Stanley, R. J., Levitt, R. G. and Sagel, S. S.: Use of CT in evaluation of postcystectomy patients. AJR, 136: 483, 1981. 12. Council on Scientific Affairs. Report of the Panel on Magnetic Resonance Imaging: Magnetic resonance imaging of the abdomen and pelvis. J.A.M.A., 261: 420, 1989. 13. Parra, R. 0., Wolf, R. M. and Ruben, R. P.: Echogenic patterns of
'I'RANSRECTAL ULTRASOUND IN LOCAL RECURRENCES local pelvic recurrences following radical pelvic surgery as evaluated by transrectal ultrasonography. J. Urol., part 2, 137: 243A, abstract 557, 1987.
EDITORIAL COMMENTS The authors note another use for transrectal ultrasound, that is assessment of the postoperative male pelvis. While the majority of the patients described had palpable abnormalities on digital rectal examination and would have merited biopsy regardless of ultrasound, in several the recurrences were detected only by ultrasound, which was performed for persistent, unexplained symptoms and/or elevated PSA levels. On the basis of this study a strong argument could be made for the adjunctive use of transrectal ultrasound in any man who after lower tract extirpation for cancer has signs or symptoms that would be attributable to recurrence. A drawback of transrectal ultrasound in this setting appears to be its lack of specificity, for example it cannot differentiate between postoperative fibrosis and malignancy. No doubt in the future transrectal ultrasound will be critically compared to the more expensive but more specific MRI, which does appear to have this tissue differentiating capability and whose use may spare the patient the need for biopsy when the tissue appearance indicates only fibrosis. Howard M. Pollack 531 Ashmead Road Cheltenham, Pennsylvania The authors have shown that transrectal ultrasonography is able to
709
detect pelvic recurrence after radical prostatectomy and cystoprostatectomy but the question remains as to how this imaging modality should be used. PSA has been proved to be a sensitive indicator of tumor recurrence after radical prostatectomy and, therefore, transrectal ultrasonography may be indicated in patients without digitally palpable abnormalities but elevated marker levels. The presence of recurrent prostatic carcinoma without an abnormal PSA level and/or digital rectal examination would be unusual and, therefore, the use of transrectal ultrasonography in patients without abnormal findings would probably be unrewarding. Obviously, recurrence after cystoprostatectomy for transitional cell carcinoma of the bladder would not be accompanied by changes in tumor markers but as shown by the authors most of the patients (8 of 11) had an abnormal digital rectal examination. Ultrasound would probably be of value in those with suspected local recurrence or who have a high likelihood of recurrence based on pathological stage of the excised tumor. Additionally, as noted by the authors, ultrasound guided biopsies would be of value to confirm tumor presence or absence. Finally, in patients who are treated with adjunctive therapy (for example androgen deprivation, chemotherapy or radiation therapy) transrectal ultrasound would be of value to document tumor response based primarily on changes in size, which can be determined accurately and reproducibly with this imaging modality. Martin I. Resnick Division of Urology University Hospitals of Cleveland Cleveland, Ohio
Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC,
THE USE OF TRANSRECTAL ULTRASOUND IN THE DETECTION AND EVALUATION OF LOCAL PELVIC RECURRENCES AFTER A RADICAL UROLOGICAL PELVIC OPERATION RAUL 0. PARRA, RICHARD M. WOLF
AND
ROBERT P. HUBEN
From the St. Louis University Medical Center, St. Louis, Missouri, and Roswell Park Memorial Institute, Buffalo, New York
ABSTRACT
Transrectal ultrasound was performed in 20 patients with suspected local pelvic recurrence after a radical pelvic operation: 9 had undergone radical prostatectomy and 11 had undergone radical cystoprostatectomy. Transrectal sonography verified the presence of recurrence in 19 of 20 patients (95%) and this was confirmed by biopsy of the visualized lesions. Analysis of the sonographic echo patterns encountered revealed that in 14 of 19 recurrent neoplasms (71.5%) the echogenic pattern was hypoechoic. In the remaining 6 patients (31.5%) the echo pattern was isoechoic. No hyperechoic lesions were noted. Based upon our findings and because of the low costs compared to other diagnostic modalities transrectal ultrasound represents an ideal technique to compliment the digital rectal examination in evaluation of patients suspected of harboring a local pelvic recurrence after a radical pelvic operation. (J. Ural., 144: 707-709, 1990) Patients who undergo a radical pelvic operation with the intent of cure of either prostate or bladder cancer require careful periodic monitoring for the possibility of tumor recurrence. The presence of local recurrence sometimes is the only indication of treatment failure, whereas distant metastatic disease is readily recognized by the use of conventional radiological studies, radionuclide scans or tumor markers. An inexpensive and accurate means to image local recurrences has not been available. Recently, the use of transrectal ultrasound has gained recognition in the diagnosis and staging of prostatic carcinomao 1 - 6 We applied this modality in 20 consecutive patients with a suspected local pelvic recurrence after radical prostatectomy or radical cystectomy and we report our experience. MATERIALS AND METHODS
A total of 20 men with suspected local pelvic recurrences underwent evaluation with transrectal ultrasound between July 1982 and March 1989. Patient age ranged from 43 to 60 years (mean age 5205 years)" Eleven patients had undergone radical cystoprostatectomy for invasive transitional cell carcinoma of the bladder (pathological stage pT2 in 6, pT3a in 3 and pT3b in 2), while 9 had undergone radical prostatectomy (pathological stage A2 in 1, B2 in 4 and C in 4). Pathological stage was based on the histological evaluation of the surgical specimen. An abnormality detected during digital rectal examination was the most common form of presentation" An abnormal digital rectal examination was defined as any induration or mass in the lower pelvis during a routine physical examination" Such findings were present in 7 of 9 and 8 of 11 patients after radical prostatectomy and cystectomy, respectively. In 2 of the men after radical prostatectomy the digital rectal examination was reported as normal but elevated levels of serum prostatic specific antigen (PSA) in the presence of a normal bone scan led to further investigation. The levels in these men were 28.6 and 31 ng./dl. individually. In only 2 other patients were concomitant PSA level determinations done and in both no significant detectable levels were present. Of the 3 patients who had a normal digital rectal examination after radical cystoprostatectomy 1 presented with lower abdominal pain, and 2 presented with deterioration of the clinical status and no evidence of distant metastatic disease on further evaluation. Transrectal ultrasound examination of the pelvis was performed with an Aloka-SSD-501 chair-mounted model with a 3.5 MHz. axial Accepted for publication March 28, 1990.
transducer in 8 patients during our early experience. A BruelKjaer model 1849 or a Kretz model 310 device, both with axial and sagittal 7.5 MHz. high frequency transducers, respectively, was used in the latter 11 patients. Selected views were recorded with either self-developing film or with images obtained from a Mitsubishi thermal printer. A study was considered positive if a mass was detected and confirmed on real-time scanning, so as not to be confused with loops of bowel present in the postoperative pelvis. Lesions were classified as hypoechoic if the sonographic appearance was less echogenic than the surrounding tissues, isoechoic if the sonographic features were not clearly differentiated from surrounding structures and hyperechoic if the lesion was significantly more echogenic than adjacent tissues. Computerized tomography (CT) was only available in 4 post-radical cystectomy patients and, therefore, no meaningful comparison between the 2 modalities could be done. All suspected lesions were biopsied transrectally after appropriate antibiotic coverage. In the group studied with the chair-mounted equipment no ultrasound guided biopsy capability was available, so that these 8 patients underwent standard digitally guided needle biopsies of the masses with a 14 gauge Tru-Cut* needle" The remaining 11 patients underwent ultrasound guided biopsies with a Biopty gun.t In all instances sufficient tissue adequate for histopathological diagnosis was obtained. RESULTS
Transrectal ultrasound visualized an abnormality in all 20 patients, 19 of whom were confirmed to have local tumor recurrence by needle biopsy. An analysis of the echogenic patterns obtained revealed that in the majority of patients (14 of 19 recurrences, or 71.5%) the echogenic pattern was hypoechoic (7 in the post-radical prostatectomy and 7 in the postradical cystectomy groups, see figure). In the remaining 6 patients (31.5%) the pattern was interpreted as isoechoic (2 after radical prostatectomy and 4 after radical cystectomy). The only patient with a false positive examination had an isoechoic mixed lesion that was biopsied under ultrasound guidance and was consistent with scar tissue. No hyperechoic lesions were found. The histopathological origin and characteristics of the tumor recurrences had no bearing or correlation in regard to the echogenicity of the lesions as demonstrated on * Travenol Laboratories, Inc., Deerfield, Illinois.
t Bard Urological, Murray Hill, New Jersey.
708
PARRA, WOLF AND HUBEN
Transverse scan of small nonpalpable recurrence after radical prostatectomy shows typical hypoechoic anterior location (3.5 MHz.). transrectal ultrasound. The size of the recurrences detected by ultrasonography ranged from 2.5 to 7 cm. with a mean of 4. 7 cm. Unfortunately, in this study no sonographic volume determinations of the lesions were performed routinely, which in retrospect would have given a more precise measurement. The recurrences were consistently either in the anterior or anterolateral location in relation to the rectum as seen by endorectal sonography. Transrectal ultrasound examinations were all tolerated with minimal complaints from the patients and no biopsy-related complications were encountered, except for discomfort in patients who underwent digitally guided Tru-Cut needle biopsies. A direct comparison between the sonographic images and the CT scan in the 4 patients in whom both studies were done simultaneously showed that transrectal ultrasound was able to delineate the recurrent lesions more readily than CT. DISCUSSION
The incidence of local pelvic recurrences after radical prostatectomy and radical cystoprostatectomy reported in the literature is 10% in the former group 7 • 8 and ranges between 9 and 28% in the latter group depending upon whether preoperative radiation therapy was used. 9 Most commonly, such recurrences are suspected based on deterioration of the clinical status or a palpable abnormality during digital rectal examination. However, digital rectal examination is a subjective examination that cannot readily differentiate between malignant and benign tissues. Therefore, consistency of information between examiners can vary widely, thus, making reliable documentation difficult. CT of the pelvis often is used in the preoperative staging of individuals with prostate and bladder cancer with sometimes conflicting results. 10 Lee and associates reported on the use of this modality in the evaluation of patients after radical cystoprostatectomy. They were able to define masses consistent with recurrent neoplasms in 7 of 8 patients. 11 The lesions found were large in volume and, therefore, easily detectable. CT lacks sufficient sensitivity to detect lesions smaller than 2 cm. The technique also is expensive and has the risk of exposure of the patient to radiation and contrast material. Furthermore, when surgical hemostatic clips are used images may be hindered by bothersome artifacts. Even though only 4 of our patients also underwent concomitant CT evaluation ultrasound proved to be more valuable, since CT was unable to define these tumors easily. This finding may be due to the fact that most of the recurrences documented were small in size and lower down in the pelvis, thus, they were easier to detect by ultrasound. However, the numbers available are too small to
make a true comparison between both modalities. Magnetic resonance imaging (MRI) of the pelvis is in a state of evolution 12 and, although it holds great promise, its use in the postoperative patient may be limited, especially when metal clips are present. In addition, availability and costs also must be considered. Transrectal ultrasound has extended our capability to examine the prostate gland. 1- 6 Therefore, this technique lends itself to be applied readily to the study of the postoperative pelvis. In all of our patients we were able to visualize an abnormality clearly, 19 of which represented a tumor recurrence based upon the biopsy material. All patients studied had clinical indications for performance of transrectal ultrasonography based either on abnormalities discovered during digital rectal examination or other clinical conditions attesting to recurrent disease. The echogenicity is predominantly hypoechoic as seen in 71.5% of the cases, which had been noted previously in our early experience. 13 The sensitivity of transrectal ultrasound over digital rectal examination did not prove to be far superior, since 15 of the 20 men also had a suspicious digital rectal examination. Presently, transrectal ultrasound is unable to differentiate clearly a scar from malignant tissue. However, we believe that transrectal ultrasound adds the ability to measure objectively and to document tumor size and location, which can be helpful in the followup of future treatment response or progression of the disease. In addition, ultrasound-guided biopsies can be performed more accurately with minimal discomfort and morbidity. In conclusion, transrectal ultrasound represents a useful imaging modality that can be used adjunctively with digital rectal examination in the documentation of local pelvic recurrences. REFERENCES
1. Resnick, M. I., Willard, J. W. and Boyce, W. M.: Transrectal
ultrasonography in the evaluation of patients with prostatic carcinoma. J. Urol., 124: 482, 1980. 2. Spirnack, J. P. and Resnick, M. I.: Ultrasound and the evaluation of the prostate. In: New Techniques in Urology. Edited by R. W. deVere White and J.M. Palmer. Mt. Kisco, New York: Futura Publishing Co., chapt. 16, pp. 251-268, 1984. 3. Lee, F., Gray, J. M., McLeary, R. D., Meadows, T. R., Kumasaka, G. H., Borkaza, G. S., Straub, W. H., Lee, F., Jr., Solomon, M. H., McHugh, T. A. and Wolf, R. M.: Transrectal ultrasound in the diagnosis of prostate cancer: location, echogenicity, histopathology, and staging. Prostate, 7: 117, 1985. 4. Lee, F., Gray, J. M., McLeary, R. D., Lee, F., Jr., McHugh, T. A., Solomon, M. M., Kumasaka, G. H., Staub, W. H., Borlaza, G. S. and Murphy, G. P.: Prostatic evaluation by transrectal sonography: criteria for diagnosis of early carcinoma. Radiology, 158: 92, 1986.
5. Rifkin, M. D., Friedland, G. W. and Shortliffe, L.: Prostatic evaluation by transrectal endosonography: detection of carcinoma. Radiology, 158: 85, 1986. 6. Waterhouse, R. L. and Resnick, M. I.: The use of transrectal prostatic ultrasonography in the evaluation of patients with prostatic carcinoma. J. Urol., 141: 233, 1989. 7. Walsh, P. C.: Radical prostatectomy, preservation of sexual function, cancer control. The controversy. Urol. Clin. N. Amer., 14: 663, 1987. 8. Robey, L. E. and Schellhammer, P. F.: Local failure after definitive therapy for prostatic cancer. J. Urol., 137: 613, 1987.
9. Crawford, E. D., Das, S. and Smith, J. A., Jr.: Preoperative radiation therapy in the treatment of bladder cancer. Urol. Clin. N. Amer., 14: 781, 1987. 10. Sawczuk, I. S., deVere White, R., Gold, R. P. and Olsson, C. A.: Sensitivity of computed tomography in evaluation of pelvic lymph node metastasis from carcinoma of bladder and prostate. Urology, 21: 81, 1983. 11. Lee, J. K., McClennan, B. L., Stanley, R. J., Levitt, R. G. and Sagel, S. S.: Use of CT in evaluation of postcystectomy patients. AJR, 136: 483, 1981. 12. Council on Scientific Affairs. Report of the Panel on Magnetic Resonance Imaging: Magnetic resonance imaging of the abdomen and pelvis. J.A.M.A., 261: 420, 1989. 13. Parra, R. 0., Wolf, R. M. and Ruben, R. P.: Echogenic patterns of
'I'RANSRECTAL ULTRASOUND IN LOCAL RECURRENCES local pelvic recurrences following radical pelvic surgery as evaluated by transrectal ultrasonography. J. Urol., part 2, 137: 243A, abstract 557, 1987.
EDITORIAL COMMENTS The authors note another use for transrectal ultrasound, that is assessment of the postoperative male pelvis. While the majority of the patients described had palpable abnormalities on digital rectal examination and would have merited biopsy regardless of ultrasound, in several the recurrences were detected only by ultrasound, which was performed for persistent, unexplained symptoms and/or elevated PSA levels. On the basis of this study a strong argument could be made for the adjunctive use of transrectal ultrasound in any man who after lower tract extirpation for cancer has signs or symptoms that would be attributable to recurrence. A drawback of transrectal ultrasound in this setting appears to be its lack of specificity, for example it cannot differentiate between postoperative fibrosis and malignancy. No doubt in the future transrectal ultrasound will be critically compared to the more expensive but more specific MRI, which does appear to have this tissue differentiating capability and whose use may spare the patient the need for biopsy when the tissue appearance indicates only fibrosis. Howard M. Pollack 531 Ashmead Road Cheltenham, Pennsylvania The authors have shown that transrectal ultrasonography is able to
709
detect pelvic recurrence after radical prostatectomy and cystoprostatectomy but the question remains as to how this imaging modality should be used. PSA has been proved to be a sensitive indicator of tumor recurrence after radical prostatectomy and, therefore, transrectal ultrasonography may be indicated in patients without digitally palpable abnormalities but elevated marker levels. The presence of recurrent prostatic carcinoma without an abnormal PSA level and/or digital rectal examination would be unusual and, therefore, the use of transrectal ultrasonography in patients without abnormal findings would probably be unrewarding. Obviously, recurrence after cystoprostatectomy for transitional cell carcinoma of the bladder would not be accompanied by changes in tumor markers but as shown by the authors most of the patients (8 of 11) had an abnormal digital rectal examination. Ultrasound would probably be of value in those with suspected local recurrence or who have a high likelihood of recurrence based on pathological stage of the excised tumor. Additionally, as noted by the authors, ultrasound guided biopsies would be of value to confirm tumor presence or absence. Finally, in patients who are treated with adjunctive therapy (for example androgen deprivation, chemotherapy or radiation therapy) transrectal ultrasound would be of value to document tumor response based primarily on changes in size, which can be determined accurately and reproducibly with this imaging modality. Martin I. Resnick Division of Urology University Hospitals of Cleveland Cleveland, Ohio