RSS-Feed abonnieren
DOI: 10.1055/a-2632-4341
Diagnostic accuracy of the muscle-retracting sign for determining deep submucosal invasion in early rectal cancer: a prospective observational study

Abstract
Background
This study aimed to determine the accuracy of the muscle-retracting sign (MRS) for the detection of deep submucosal invasion (SMI) in early rectal cancer.
Methods
In this prospective observational single-center study, consecutive rectal lesions that underwent endoscopic resection using the pocket-detection method (PDM) between August 2023 and March 2025 were included. Directionality of the initial submucosal dissection targeted any morphologic or surface vascular pattern at risk of deep SMI to attempt MRS identification. Histopathology was the reference standard for MRS diagnostic accuracy in detecting deep SMI.
Results
38 rectal lesions (median size 30 mm [interquartile range 20]) were included. The PDM for detection of the MRS was successful in all cases, with MRS positivity in 15/38 cases (39.5%). Deep SMI was confirmed in 15/38 cases (39.5%). The accuracy of MRS positivity for deep SMI detection was 84.2% (95%CI 69.6%–92.6%), with a sensitivity of 80.0% (95%CI 54.8%–92.9%), specificity of 87.0% (95%CI 67.9%–95.5%), positive likelihood ratio of 6.13, negative likelihood ratio of 0.23, and area under the receiver operating characteristic curve of 0.83 (95%CI 0.71–0.96). The rate of R0 resection was 92.1% (35/38).
Conclusions
The MRS detected using the PDM demonstrated moderate-to-high accuracy for the prediction of deep SMI in early rectal cancer. This finding may allow the precise selection of an endoscopic resection strategy based on invasion depth for the minimally invasive treatment of early rectal cancer.
Publikationsverlauf
Eingereicht: 27. März 2025
Angenommen nach Revision: 10. Juni 2025
Accepted Manuscript online:
10. Juni 2025
Artikel online veröffentlicht:
08. August 2025
© 2025. Thieme. All rights reserved.
Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
-
References
- 1 Pimentel-Nunes P, Libâno D, Bastiaansen BA. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54: 591-622
- 2 Cronin O, Sidhu M, Shahidi N. et al. Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment. Gastrointest Endosc 2022; 96: 118-124
- 3 O'Sullivan T, Craciun A, Byth K. et al. A simplified algorithm to evaluate the risk of submucosal invasive cancer in large (≥20 mm) nonpedunculated colonic polyps. Endoscopy 2024; 56: 596-604
- 4 D'Amico F, Amato A, Iannone A. et al. Risk of covert submucosal cancer in patients with granular mixed laterally spreading tumors. Clin Gastroenterol Hepatol 2021; 19: 1395-1401
- 5 Dulskas A, Kavaliauskas P, Pilipavicius L. et al. Long-term bowel dysfunction following low anterior resection. Sci Rep 2020; 10: 11882
- 6 Kobayashi N, Takeuchi Y, Ohata K. et al. Outcomes of endoscopic submucosal dissection for colorectal neoplasms: Prospective, multicenter, cohort trial. Dig Endosc 2022; 34: 1042-1051
- 7 Watanabe D, Toyonaga T, Ooi M. et al. Clinical outcomes of deep invasive submucosal colorectal cancer after ESD. Surg Endosc 2018; 32: 2123-2130
- 8 Moons LMG, Bastiaansen BAJ, Richir MC. et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54: 993-998
- 9 Argenziano ME, Sorge A, Poortmans PJ. et al. Knife-assisted full-thickness resection guided by pocket detection method for detection and complete excision of deeply invasive rectal cancer. VideoGIE 2024; 10: 191-193
- 10 Argenziano ME, Sorge A, Hoorens A. et al. Knife-assisted full-thickness resection guided by the pocket-detection method for posterior deeply invasive rectal cancer: A novel endoscopic approach (with video). DEN Open 2025; 5: e70116
- 11 Toyonaga T, Tanaka S, Man-l M. et al. Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection. Endosc Int Open 2015; 3: E246-E2451
- 12 Albouys J, Manzah I, Schaefer M. et al. Prevalence and clinical significance of the muscle retracting sign during endoscopic submucosal dissection of large macronodular colorectal lesions (with videos). Gastrointest Endosc 2024; 99: 398-407
- 13 Yamada M, Saito Y, Sakamoto T. et al. Endoscopic predictors of deep submucosal invasion in colorectal laterally spreading tumors. Endoscopy 2016; 48: 456-464
- 14 Sano Y, Tanaka S, Kudo S-E. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
- 15 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
- 16 Chan BPH, Patel R, Mbuagbaw L. et al. EUS versus magnetic resonance imaging in staging rectal adenocarcinoma: a diagnostic test accuracy meta-analysis. Gastrointest Endosc 2019; 90: 196-203.e1
- 17 Zwager LW, Bastiaansen BAJ, Montazeri NSM. et al. Deep submucosal invasion is not an independent risk factor for lymph node metastasis in T1 colorectal cancer: a meta-analysis. Gastroenterology 2022; 163: 174-189