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 ...
Acta Medica Okayama Volume 56, Issue 2
2002
Article 9
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, †
c Copyright 1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.
Intraluminal implantation of rectal carcinoma successfully resected by endoscopy.∗ 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 implantation 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
Tanakaya et al.: Intraluminal implantation of rectal carcinoma successfully
Act aMed.Okay ama,2002 Vol .56,No.2,pp.117119 ｃ2002byOka Copyr i ght ya maUni ve r s i t yMe di c a lSc hool .
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I nt r al umi nalI mpl ant at i onofRect alCar ci noma Successf ul l yResect edby Endoscopy Kohj iTanakaya ,Nor i hi r oTe r amot o,Ei j iKonaga,Hi t os hiTake uc hi, Yos hi mas aYas ui,Aki r aTake da,Yas uhi r oYunoki,andI c hi r oMur akami De p a r t me n to fSu r g e r ya n d De p a r t me n to fPa t h o l o g y ,I wa k u n iNa t i o n a lHo s p i t a l , I wa k u n i7 4 08 5 1 0 ,J a p a n
A5 5 ye ar ol dJapane s ewomanpr e s e nt e datourhos pi t alc ompl ai ni ngofhe mat oc he z i a4mont hs af t e rs ur ge r yf orar e c t alc ar c i noma.A pr oc t os c opyr e ve al e d2pr ot ube r antl e s i onsi nt her e c t um, 5mm anal l yf r om t heanas t omot i cs ut ur el i ne .Thedi agnos i sofade noc ar c i nomawasc onfir me dby bi ops y.I twasc ons i de r e dt hatt he s el e s i onswe r ec aus e dbyi nt r al umi nali mpl ant at i onf r om t he pr i mar yr e c t alc ar c i noma.Thepat i e ntunde r we ntane ndos c opi cr e s e c t i onf ort he s er e c ur r e ntl e s i ons andhasr e mai ne ds t abl e ,wi t hne i t he rr e c ur r e nc enorme t as t as i s ,i nt he7ye ar ss i nc et her e s e c t i on. Forr e c t alc ar c i noma,wepr opos ee ar l yf ol l owupbypr oc t os c opy,name l ywi t hi n4mont hsaf t e r s ur ge r y. Ke ywor ds :i n t r a l u mi n a li mp l a n t a t i o n ,r e c t a lc a r c i n o ma ,e n d o s c o p i cr e s e c t i o n
oi mp r o v et h ep r o g n o s i sa n ds u r v i v a lo fp a t i e n t s wi t hc o l o r e c t a lc a r c i n o ma ,e a r l yd e t e c t i o no fa n y r e c u r r e n c ei sv e r yi mp o r t a n t ,e s p e c i a l l yi nc a s e sf o rwh i c h c u r a t i v er e s e c t i o ni sp o s s i b l e . Wer e p o r tac a s eo fa ni n t r a l u mi n a li mp l a n t a t i o nf r o m ar e c t a lc a r c i n o ma ,f o u n do n l y4mo n t h sa f t e rs u r g e r y , a n dt h es u c c e s s f u lr e mo v a lo ft h er e c u r r e n tl e s i o n sb y e n d o s c o p i cr e s e c t i o n .Wea l s od i s c u s si n t r a l u mi n a li mp l a n t a t i o no fc o l o r e c t a lc a r c i n o ma ,i n c l u d i n gi t sp r e v e n t i o na n ds u r v e i l l a n c e .
l a y e rp r o c e d u r ewi t h o u ts t a p l i n gd e v i c e s .Wed i dn o t p e r f o r m i n t r a o p e r a t i v eb o we li r r i g a t i o n . Pr e o p e r a t i v e e x a mi n a t i o n si n v o l v i n gb a r i u me n e maa n dc o l o n o s c o p y s h o we dar e c t a lt u mo r .Ho we v e r ,t h e r ewa sn oo t h e r p o l y p o i dl e s i o ni nt h emu c o s aa d j a c e n tt ot h er e c t a lt u mo r b e f o r es u r g e r y( Fi g .1 ) .Gr o s sfi n d i n g so ft h er e s e c t e d s p e c i me nd e mo n s t r a t e dawe l l d e fi n e du l c e r a t i v el e s i o no f t h er e c t u mme a s u r i n g4 . 4× 4 . 0c m.Th el e n g t hf r o mt h e t u mo rt ot h ed i s t a lma r g i nwa s5 . 1c m. Th eh i s t o l o g i c a l fi n d i n g so ft h er e c t a l c a r c i n o mai n c l u d e d:mo d e r a t e l yd ie r e n t i a t e da d e n o c a r c i n o mai n v a d e di n t o t h es u b s e r o s a ,n ol y mp h n o d eme t a s t a s i s ,a n dn oma l i g Cas eRe por t n a n tc e l l st ot h ed i s t a lma r g i no ft h er e s e c t e ds p e c i me n . A5 5 y e a r o l dJ a p a n e s ewo ma nu n d e r we n tl o wa n t e - Af t e rt h eo p e r a t i o n ,t h ep a t i e n twa st r e a t e dd a i l ywi t h3 0 0 r i o rr e s e c t i o nf o rar e c t a lc a r c i n o mao nJ u n e2 4 ,1 9 9 3 . mgo ffl u o r o u r a c i lo r a l l ya sa d j u v a n tc h e mo t h e r a p y . Th ee n d t o e n da n a s t o mo s i swa sma d eu s i n gal a y e r t o OnNo v e mb e r1 ,1 9 9 3 ,t h ep a t i e n tp r e s e n t e da to u r h o s p i t a lc o mp l a i n i n go fh e ma t o c h e z i a .A p r o c t o s c o p y r e v e a l e d2p r o t u b e r a n tl e s i o n si nt h er e c t u m,wh i c hwe r e Re c e i v e dJ u n e2 5 ,2 0 0 1;a c c e p t e dSe p t e mb e r2 0 ,2 0 0 1 . l o c a t e d 5 m ma n a l l y f r o mt h e a n a s t o m o t i c l i n e . O n e l e s i o n ＋8 ＋8 -8 -3 -7 Co r r e s p o n d i n ga u t h o r .Ph o n e: 1 8 2 7 3 1 7 1 2 1 ;Fa x: 1 2 7 1 0 5 9 ＠i （K.Ta ） wa s1 0mm i nd i a me t e r ,a n dt h eo t h e rwa s2mm ( Fi g . Ema i l : t a n a k a y a wa k u n i n h . g o . j p n a k a y a
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Produced by The Berkeley Electronic Press, 2002
1
Acta Medica Okayama, Vol. 56 [2002], Iss. 2, Art. 9
118 Tanakay aetal .
2 ) .Th ed i a g n o s i so fa d e n o c a r c i n o mawa sc o n fi r me db y b i o p s y .I twa sc o n s i d e r e dt h a tt h e s el e s i o n swe r ec a u s e d b yi n t r a l u mi n a li mp l a n t a t i o nf r o m t h ep r i ma r yr e c t a l c a r c i n o ma .Th el a b o r a t o r yfi n d i n g swe r eu n r e ma r k a b l e . Tu mo rma r k e r swe r ea l s on o r ma l( c a r c i n o e mb r y o n i c /ml a n t i g e n:1 . 0n g ) . Th ep a t i e n tu n d e r we n tafl e x i b l efi b e r o p t i ce n d o s c o p i c r e s e c t i o nf o rt h e s er e c u r r e n tl e s i o n s .Hi s t o l o g i cfi n d i n g s s h o we dt h a tt h e s el e s i o n swe r emo d e r a t e l yd ie r e n t i a t e d
Act aMed.Okay ama Vol .56,No.2
a d e n o c a r c i n o mao ft h es a met y p ea st h ep r i ma r yt u mo r , a n ds u g g e s t e dt h a tt h e s er e c u r r e n tl e s i o n swe r ec o mp l e t e l yr e s e c t e d( Fi g .3 ) . Th ep a t i e n ti sn o ws t a b l e ,h a v i n ge x p e r i e n c e dn e i t h e r r e c u r r e n c en o rme t a s t a s i s7y e a r sa f t e rt h ee n d o s c o p i c r e s e c t i o n .
Di s c us s i on Co l o r e c t a lc a r c i n o mac a ns p r e a di nma n ywa y s :b y d i r e c te x t e n s i o n ,p e r i t o n e a ls e e d i n g ,l y mp h a t i cs p r e a d i n g , h e ma t o g e n o u ss p r e a d i n g ,a n di n t r a l u mi n a li mp l a n t a t i o n . Se v e r a lr e p o r t sh a v eo b s e r v e dt h a te x f o l i a t e dma l i g n a n t c e l l sa r ec a p a b l eo fi mp l a n t i n gt h e ms e l v e si nt h er a w b o we ls u r f a c e .Amo n gt h es i t e si nwh i c hi n t r a l u mi n a l i mp l a n t a t i o no c c u r s ,n o r ma lmu c o s ai su n c o mmo n . An a s t o mo t i cs u t u r el i n e s ,e s p e c i a l l yt h o s et h a th a v eb e e n
Fi g.1 Pr e o p e r a t i v ee x a mi n a t i o n so fb a r i u me n e mas h o we da r e c t a lt u mo r( a r r o ws ) .Th e r ewa sn oo t h e rl e s i o ni nt h er e c t u m.
Fi g.2 Pr o c t o s c o p yr e v e a l e d2p r o t u b e r a n tl e s i o n si nt h er e c t u m a p a r tf r o mt h ea n a s t o mo t i cl i n e( a r r o ws ) .
http://escholarship.lib.okayama-u.ac.jp/amo/vol56/iss2/9
Fi g.3 Hi s t o l o g i cfi n d i n g so ft h el a r g e rl e s i o nr e v e a l e dt h a tt h e l e s i o ni n v a d e di n t ot h es u b mu c o s as l i g h t l y ,a n dwa sc o mp l e t e l y r e s e c t e d( HE:a,l o wp o we rfi e l d;b,mi d d l ep o we rfi e l d ) .
2
Tanakaya et al.: Intraluminal implantation of rectal carcinoma successfully
Apr i l2002
s t a p l e d ,a n dr e c t a ls t u mp sr e s u l t i n gf r o m Ha r t ma n ns p r o c e d u r ea r ec o mmo ns i t e sf o ri n t r a l u mi n a li mp l a n t a t i o n t oo c c u r .He mo r r h o i d e c t o mywo u n d so rfi s t u l ai na n o ［1 ］.I h a v ea l s ob e e nr e p o r t e d ,2 nt h ep r e s e n tc a s e ,a s b o t ho ft h el e s i o n swe r ef o u n d5mm a n a l l yf r o mt h e a n a s t o mo t i cl i n e ,t h ei mp l a n t a t i o nme t a s t a s i smi g h th a v e o c c u r r e di nmu c o s ai n j u r e db ya no p e r a t i n gp r o c e d u r e s u c ha sb o we lc l a mp i n g . Top r e v e n ti n t r a l u mi n a li mp l a n t a t i o n ,s e v e r a lme t h o d s h a v eb e e nr e p o r t e d:i n t r a o p e r a t i v ec o l o r e c t a li r r i g a t i o n wi t hc y t o t o x i ca g e n t ss u c ha sp o v i d o n e i o d i n eo rf o r ma l i n , an o t o u c hi s o l a t i o nt e c h n i q u e ,e a r l ya p p l i c a t i o no fb o we l ［3 -5 ］.I l i g a t u r e ,a n da d j u v a n tr a d i o a n dc h e mo t h e r a p y n t h ep r e s e n tc a s e ,wet r i e dt omi n i mi z et u mo rma n i p u l a t i o n a n dp e r f o r me da d j u v a n tc h e mo t h e r a p y ,b u td i dn o tp e r f o r mi n t r a o p e r a t i v eb o we li r r i g a t i o no re a r l ya p p l i c a t i o n o fb o we ll i g a t u r e . Th e ee c t i v e n e s so fc o l o n o s c o p i cs u r v e i l l a n c eo f i n t r a l u mi n a ll o c a lr e c u r r e n c eh a sb e e nr e p o r t e d .Bu tt h e b e n e fi tp r o v i d e db yc o l o n o s c o p yr e ma i n su n p r o v e n ,a n d t h eb e s tt i mef o re x a mi n a t i o nh a sn o tb e e nd e t e r mi n e d ［6 ］.I nt h ep r e s e n tc a s e ,t h ei n t r a l u mi n a li mp l a n t a t i o n wa sf o u n do n l y4mo n t h sa f t e rs u r g e r y .A c a s eo f i n t r a l u mi n a li mp l a n t a t i o nt h a th a dd e v e l o p e do n l y3 ［7 ］.Pi mo n t h sa f t e rs u r g e r yh a sa l s or e p o r t e d e t r ae ta l . r e c o mme n d e da ni n t e n s ef o l l o wu pp l a n ,a tl e a s ti n ［8 ］.Th p a t i e n t swi t hr e c t a lc a r c i n o ma e i rf o l l o wu pp l a n a f t e rs u r g e r yi n v o l v e de x a mi n a t i o n se v e r y 3 mo n t h s d u r i n gt h efi r s t2y e a r s ,a t6mo n t h sf o rt h en e x t3y e a r s ,
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I nt r al umi nalI mpl ant at i onofRect alCa 119
a n do n c eay e a rt h e r e a f t e r .Ho we v e r ,c o n s i d e r i n gt h a tt h e s c r e e n i n gi sn o tc o s t ee c t i v e ,c o l o n o s c o p yi sn o ta p p r o p r i a t ef o ri n t e n s ee x a mi n a t i o n .Th e r e f o r e ,wep r o p o s e t h a ta n t e r i o rr e s e c t i o nf o rr e c t a lc a r c i n o mas h o u l db e f o l l o we du pb yp r o c t o s c o p ya n dt h a tt h i so c c u re a r l y , wi t h i n4mo n t h sa f t e rs u r g e r y .
Re f e r e nc e s 1 . Ki l l i n g b a c kM,Wi l s o nE a n dHu g h e sESR:An a lme t a s t a s i sf r o m c a r c i n o mao ft h er e c t u ma n dc o l o n .Au s tNZJSu r g( 1 9 6 5 ) ,1 7 8 1 8 7 . 2 . Th o ma s DJ a n d Th o mp s o n MR:I mp l a n t a t i o n me t a s t a s i sf r o m a d e n o c a r c i n o mao fs i g mo i dc o l o ni n t ofi s t u l ai na n o .JRSo cMe d ( 1 9 9 2 ) ,3 6 1 . 3 . Ba s h aG,Pe n n i n c k xF,Me b i sJ ,Fi l e zL,Ge b o e sKa n dYa pP:Lo c a l a n ds y s t e mi cee c t so fi n t r a o p e r a t i v ewh o l e c o l o nwa s h o u twi t h5p e r -2 c e n tp o v i d o n e i o d i n e .BrJSu r g( 1 9 9 9 ) ,2 1 9 2 6 . 4 . Lo n gRTa n dEd wa r d sRH:I mp l a n t a t i o nme t a s t a s i sa sac a u s eo fl o c a l r e c u r r e n c eo fc o l o r e c t a lc a r c i n o ma .AmJSu r g( 1 9 8 9 ) ,1 9 4 2 0 1 . 5 . Sl a n e t zCAJ r :E e c to fn ot o u c hi s o l a t i o no ns u r v i v a la n dr e c u r r e n c e i nc u r a t i v er e s e c t i o n sf o rc o l o r e c t a lc a n c e r .An nSu r gOn c o l( 1 9 9 8 ), -3 3 9 0 9 8 . 6 . Pa t c h e t tSE,Mu l c a h yHEa n dODo n o g h u eDP:Co l o n o s c o p i cs u r v e i l l a n c ea f t e rc u r a t i v er e s e c t i o nf o rc o l o r e c t a lc a n c e r .BrJSu r g( 1 9 9 3 ) -1 ,1 3 3 0 3 3 2 . 7 . Pi s a n oG,Gh i n a miE,Fa aGa n dCa g e t t iM:Lo c a lr e c u r r e n c ec a u s e d b yd i r e c ti mp l a n t a t i o nf r o mc a n c e ro ft h ec o l o n .GCh i r( 1 9 9 1 ) , -3 3 1 6 1 8 . 8 . Pi e t r aN,Sa r l iL,Co s t iR,Ou c h e miC,Gr a t t a r o l aMa n dPe r a c c h i aA: Ro l eo ff o l l o wu pi nma n a g e me n to fl o c a lr e c u r r e n c e so fc o l o r e c t a l c a n c e r :Ap r o s p e c t i v e ,r a n d o mi z e ds t u d y .Di sCo l o nRe c t u m( 1 9 9 8 ) -1 ,1 1 2 7 1 3 3 .
3
