Acta Medica Okayama
Volume
56,
Issue2 2002
Article9
A PRIL 2002
Intraluminal implantation of rectal carcinoma successfully resected by endoscopy.
Kohji Tanakaya
∗Norihiro Teramoto
†Eiji Konaga
‡Hitoshi Takeuchi
∗∗Yoshimasa Yasui
††Akira Takeda
‡‡Yasuhiro Yunoki
§Ichiro Murakami
¶∗Iwakuni National Hospital,
†Iwakuni National Hospital,
‡Iwakuni National Hospital,
∗∗Iwakuni National Hospital,
††Iwakuni National Hospital,
‡‡Iwakuni National Hospital,
§Iwakuni National Hospital,
¶Iwakuni National Hospital,
Copyright c1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.
Kohji Tanakaya, Norihiro Teramoto, Eiji Konaga, Hitoshi Takeuchi, Yoshimasa Yasui, Akira Takeda, Yasuhiro Yunoki, and Ichiro Murakami
Abstract
A 55-year-old Japanese woman presented at our hospital complaining of hematochezia 4 months after surgery for a rectal carcinoma. A proctoscopy revealed 2 protuberant lesions in the rectum, 5 mm anally from the anastomotic suture line. The diagnosis of adenocarcinoma was confirmed by biopsy. It was considered that these lesions were caused by intraluminal implanta- tion from the primary rectal carcinoma. The patient underwent an endoscopic resection for these recurrent lesions and has remained stable, with neither recurrence nor metastasis, in the 7 years since the resection. For rectal carcinoma, we propose early follow-up by proctoscopy, namely within 4 months after surgery.
KEYWORDS:intraluminal implantation, rectal carcinoma, endoscopic resection
∗PMID: 12002618 [PubMed - indexed for MEDLINE]
Copyright (C) OKAYAMA UNIVERSITY MEDICAL SCHOOL
I nt r al umi nalI mpl ant at i onofRect alCar ci noma Successf ul l yResect edbyEndoscopy
KohjiTanakaya ,NorihiroTeramoto,EijiKonaga,HitoshiTakeuchi, YoshimasaYasui,AkiraTakeda,YasuhiroYunoki,andIchiroMurakami
DepartmentofSurgeryand DepartmentofPathology,IwakuniNationalHospital, Iwakuni740‑8510,Japan
A 55-year-oldJapanesewomanpresentedatourhospitalcomplainingofhematochezia4months aftersurgeryforarectalcarcinoma.A proctoscopyrevealed2protuberantlesionsintherectum, 5mm anallyfrom theanastomoticsutureline.Thediagnosisofadenocarcinomawasconfirmedby biopsy.Itwasconsideredthattheselesionswerecausedbyintraluminalimplantationfrom the primaryrectalcarcinoma.Thepatientunderwentanendoscopicresectionfortheserecurrentlesions andhasremainedstable,withneitherrecurrencenormetastasis,inthe7yearssincetheresection.
Forrectalcarcinoma,weproposeearlyfollow-upbyproctoscopy,namelywithin4monthsafter surgery.
Keywords:intraluminalimplantation,rectalcarcinoma,endoscopicresection
T
oiwitmphcroolvoetrechtaeplcraorgcinnoosmaisa,endsarluydrvievtaeloctiofpnoatfaienntysrecurrenceisveryimportant,especiallyincasesforwhich curativere-sectionispossible.
Wereportacaseofanintraluminalimplantationfrom arectalcarcinoma,foundonly4monthsaftersurgery, andthesuccessfulremovaloftherecurrentlesionsby endoscopicresection.Wealsodiscussintraluminalim- plantationofcolorectalcarcinoma,includingitspreven- tionandsurveillance.
CaseReport
A 55-year-oldJapanesewomanunderwentlowante- riorresectionforarectalcarcinomaonJune24,1993. Theend-to-endanastomosiswasmadeusingalayer-to-
layerprocedurewithoutstaplingdevices.Wedidnot perform intraoperative bowelirrigation. Preoperative examinationsinvolvingbarium enemaandcolonoscopy showedarectaltumor.However,therewasnoother polypoidlesioninthemucosaadjacenttotherectaltumor beforesurgery(Fig.1).Grossfindingsoftheresected specimendemonstratedawell-definedulcerativelesionof therectummeasuring4.4×4.0cm.Thelengthfromthe tumortothedistalmarginwas5.1cm.
Thehistologicalfindingsoftherectalcarcinomainclud- ed:moderatelydierentiatedadenocarcinomainvadedinto thesubserosa,nolymph-nodemetastasis,andnomalig- nantcellstothedistalmarginoftheresectedspecimen. Aftertheoperation,thepatientwastreateddailywith300 mgoffluorouracilorallyasadjuvantchemotherapy.
OnNovember1,1993,thepatientpresentedatour hospitalcomplainingofhematochezia.A proctoscopy revealed2protuberantlesionsintherectum,whichwere located5mmanallyfromtheanastomoticline.Onelesion was10mm indiameter,andtheotherwas2mm (Fig.
ReceivedJune25,2001;acceptedSeptember20,2001.
Correspondingauthor.Phone:＋81‑827‑31‑7121;Fax:＋81‑827‑31‑7059 E-mail:tanakaya＠iwakuni-nh.go.jp（K.Tanakaya）
http://www.lib.okayama-u.ac.jp/www/acta/
ActaMed.Okayama,2002 Vol.56,No.2,pp.117‑119
Ca s eRe p o r t
Copyrightｃ2002byOkayamaUniversityMedicalSchool.
1 Tanakaya et al.: Intraluminal implantation of rectal carcinoma successfully
Produced by The Berkeley Electronic Press, 2002
2).Thediagnosisofadenocarcinomawasconfirmedby biopsy.Itwasconsideredthattheselesionswerecaused by intraluminalimplantation from theprimary rectal carcinoma.Thelaboratoryfindingswereunremarkable. Tumormarkerswerealso normal(carcinoembryonic antigen:1.0ng/ml).
Thepatientunderwentaflexiblefiberopticendoscopic resectionfortheserecurrentlesions.Histologicfindings showedthattheselesionsweremoderatelydierentiated
adenocarcinomaofthesametypeastheprimarytumor, andsuggestedthattheserecurrentlesionswerecomplete- lyresected(Fig.3).
Thepatientisnowstable,havingexperiencedneither recurrencenormetastasis7yearsaftertheendoscopic resection.
Discussion
Colorectalcarcinomacanspreadinmanyways:by directextension,peritonealseeding,lymphaticspreading, hematogenousspreading,andintraluminalimplantation. Severalreportshaveobservedthatexfoliatedmalignant cellsarecapableofimplantingthemselvesintheraw bowelsurface.Amongthesitesinwhichintraluminal implantation occurs, normalmucosa is uncommon. Anastomoticsuturelines,especiallythosethathavebeen
Tanakayaetal. ActaMed.Okayama Vol.56,No.2
118
Fig.2 Proctoscopyrevealed2protuberantlesionsintherectum apartfrom theanastomoticline(arrows).
Fig.1 Preoperativeexaminationsofbarium enemashoweda rectaltumor(arrows).Therewasnootherlesionintherectum.
Fig.3 Histologicfindingsofthelargerlesionrevealedthatthe lesioninvadedintothesubmucosaslightly,andwascompletely resected(HE:a,lowpowerfield;b,middlepowerfield).
stapled,andrectalstumpsresultingfrom Hartmannʼs procedurearecommonsitesforintraluminalimplantation tooccur.Hemorrhoidectomywoundsorfistulainano havealsobeenreported［1,2］.Inthepresentcase,as bothofthelesionswerefound5mm anallyfrom the anastomoticline,theimplantationmetastasismighthave occurredinmucosainjuredbyanoperatingprocedure suchasbowelclamping.
Topreventintraluminalimplantation,severalmethods havebeenreported:intra-operativecolorectalirrigation withcytotoxicagentssuchaspovidone-iodineorformalin, ano-touchisolationtechnique,earlyapplicationofbowel ligature,andadjuvantradio-andchemotherapy［3‑5］.In thepresentcase,wetriedtominimizetumormanipulation andperformedadjuvantchemotherapy,butdidnotper- form intra-operativebowelirrigationorearlyapplication ofbowelligature.
The eectiveness ofcolonoscopic surveillance of intraluminallocalrecurrencehasbeenreported.Butthe benefitprovidedbycolonoscopyremainsunproven,and thebesttimeforexaminationhasnotbeendetermined
［6］.Inthepresentcase,theintraluminalimplantation wasfoundonly4monthsaftersurgery.A caseof intraluminalimplantation thathad developed only 3 monthsaftersurgeryhasalsoreported［7］.Pietraetal. recommended an intensefollow-up plan, atleastin patientswithrectalcarcinoma［8］.Theirfollow-upplan aftersurgery involved examinationsevery 3 months duringthefirst2years,at6monthsforthenext3years,
andonceayearthereafter.However,consideringthatthe screeningisnotcost-eective,colonoscopyisnotappro- priateforintenseexamination.Therefore,wepropose thatanteriorresectionforrectalcarcinomashouldbe followedupbyproctoscopyandthatthisoccurearly, within4monthsaftersurgery.
References
1. KillingbackM,WilsonE andHughesESR:Analmetastasisfrom carcinomaoftherectumandcolon.AustNZJSurg(1965) ,178‑ 187.
2. Thomas DJ and Thompson MR:Implantation metastasis from adenocarcinomaofsigmoidcolonintofistulainano.JRSocMed (1992) ,361.
3. BashaG,PenninckxF,MebisJ,FilezL,GeboesKandYapP:Local andsystemiceectsofintraoperativewhole-colonwashoutwith5per centpovidone-iodine.BrJSurg(1999) ,219‑226.
4. LongRTandEdwardsRH:Implantationmetastasisasacauseoflocal recurrenceofcolorectalcarcinoma.AmJSurg(1989) ,194‑201. 5. SlanetzCAJr:Eectofnotouchisolationonsurvivalandrecurrence
incurativeresectionsforcolorectalcancer.AnnSurgOncol(1998), 390‑398.
6. PatchettSE,MulcahyHEandOʼDonoghueDP:Colonoscopicsurveil- lanceaftercurativeresectionforcolorectalcancer.BrJSurg(1993)
,1330‑1332.
7. PisanoG,GhinamiE,FaaGandCagettiM:Localrecurrencecaused bydirectimplantationfrom cancerofthecolon.GChir(1991) , 316‑318.
8. PietraN,SarliL,CostiR,OuchemiC,GrattarolaMandPeracchiaA:
Roleoffollow-upinmanagementoflocalrecurrencesofcolorectal cancer:Aprospective,randomizedstudy.DisColonRectum (1998)
,1127‑1133.
IntraluminalImplantationofRectalCa
April2002 119
3 Tanakaya et al.: Intraluminal implantation of rectal carcinoma successfully
Produced by The Berkeley Electronic Press, 2002
