0:01

So this next case is also a male patient, and I promise

0:05

I have not deliberately taken on the male patients.

0:08

These are just interesting examples to highlight

0:11

some points. So this is a relatively older patient who

0:15

has rectal bleeding and, again, a biopsy-proven rectal

0:18

cancer, and we have been asked to stage the tumor.

0:21

Right off the bat, looking at the

0:23

sagittal image is interesting.

0:24

So this patient has had luminal filling with

0:29

gel, and you can see that there is a distention

0:32

of the lumen that kind of nicely lays out the

0:34

location of the overhanging edges of the cancer.

0:37

And so that's what I meant by, you know, if you're

0:40

able to do this from a logistical perspective, it

0:43

definitely adds benefit in terms of distending.

0:47

You don't want to over-distend the lumen

0:49

because it makes the patient uncomfortable.

0:51

It can also make staging a little bit difficult,

0:53

but, you know, instilling about 50 to 150 cc's of

0:57

gel should suffice in terms of luminal distention.

1:01

So here's a tip of the seminal vesicle right here.

1:03

And this is the black line of the peritoneal lining

1:06

which is extending posteriorly to the rectum, so kind

1:08

of gives you a sense of where the peritoneum inserts

1:11

and this is, again, a nice example of showing the

1:14

low external sphincter going below the level of the

1:18

most distal part of the anal canal and the internal

1:19

sphincter kind of ends right here. And so, again, just

1:24

to do the measurement, this may be more accurate

1:28

right like so. It's mid-rectal cancer, and the actual

1:31

distance of the tumor is about five centimeters.

1:34

So, fairly, a good-sized cancer in the mid-rectum.

1:39

So that's the first thing.

1:40

And then, you know, we're going to look at the oblique.

1:44

Here's a true axial, look at the

1:46

coronal, the true axial, and again, you

1:50

can nicely see the layer distention.

1:53

The question is now, we clearly see there is a

1:56

nice, uh, apple core lesion in the midrectum.

1:59

The question is, um, staging and also going

2:02

through some of the important key points.

2:05

So as you can see right here, there is, uh,

2:09

clearly extension on the left side beyond

2:11

the lumen into the adjacent mesorectal fat.

2:14

And if I just,

2:18

let me measure the distance.

2:20

So this is, um, about 7.5 millimeters extension into

2:23

49 00:02:25,280 --> 00:02:27,410 the, so it is between 5 and 15.

2:27

So this is also a T3C based on the measurement.

2:31

And then if I delete this measurement

2:34

and take the shortest in terms of here's

2:37

the outline of the mesorectal fascia.

2:39

And if I measure the, um, the shortest

2:42

distance is about from the primary tumor

2:44

extent, it's not involved or threatened.

2:47

But what is interesting compared to the other

2:49

cases is, you know, this patient has multiple lymph

2:52

nodes and also has a variant of the lymph node that

2:59

we'll be talking about in terms of what that means.