Transperineal excision: A novel and alternative surgical ...
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Transperineal excision: A novel andalternative surgical approach forpelvic recurrence of rectal cancer
Introduction
Colorectalcancer (CRC) is the third most frequently diagnosed
cancer in both men and women and the second most fatal
cancer.1 The incidence of CRC is greater in men than in women.2
CRCs are often seen in the elderly population and approximately
30% of these are localized in the rectum.2 Distal rectal cancer is
a surgical and oncological challenge. Various surgical
operations, such as abdomin operineal resection and low
anterior resection with total mesorectal excision (TME), are
performed in the management of distal rectal cancer. Although
recurrence rates have decreased to about 10% after using the
method of TME, local recurrence remains an important clinical
issue.3 Surgery is the treatment of choice but it is a difficult
procedure, with very poor prognosis. Here, we report a case of
pelvic recurrent tumor that was entirely excised by a novel and
alternative surgical method, transperineal approach, with CT-
guided wire marking.
Case Report
A 71-year-old female patient, who had undergone abdominal
operineal resection for a low rectal cancer with T2N0
pathological stage before fifteen months, was admitted to our
unit for routine follow-up. She had received a full course of
adjuvant chemoradiation following the operation. On blood
tests, cancer antigen 19.9 (CA 19-9) level was high (163 IU/mL)
with normal carcinoembryonic antigen (CEA) level (5ng/mL).
As shown in Figure 1, CT scan showed a heterogeneous
pelvic mass, 38 mm x 35 mm in size, at the left posterolateral
side of bladder. Similar lesion within definite borders was also
seen on magnetic resonance imaging. In PET/CT, an increased
18F - FDG uptake (SUVmaks: 5.1), approximately 29 mm x 25
mm in size, at the inferior left para-iliac zone was observed. CT-
guided trucut biopsy was performed. Biopsy identified an
adenocarcinoma. The pelvic mass was marked with a
CT-guided wire and was excised totally by transperineal
approach under spinal anesthesia as shown in
Figure 2. On histopathological examination,
an adenocarcinoma, evaluated as a recurrent lesion of the
Figure 2: The appearance of the area after excision of the mass,
localized between iliac bone (blue arrow) and obturatory
vein (white arrow)
Figure 1: The tomographic appearance of the pelvic mass, marked
with a wire, localized at the left posterolateral site of
bladder
Tropical Gastroenterology 2015;36(2):123–125
primary rectal cancer, was reported as shown in
Figure 3.
Discussion
The most important component for obtaining long term local
control and survival is R0 resection with sharp TME.
Additionally, the use of adjuvant radiotherapy has been shown
to reduce loco-regional recurrence (LR).4 However, patients,
treated with a curative rectal cancer resection, have a 10% risk
of developing LR.3 Close anatomic relation of the rectum to the
small pelvis makes rectal cancer proneto recurrence. LR of rectal
cancer usually occurs within the first few years following
resection of the primary.5 Similarly, the pelvic recurrence
developed fifteen months after primary surgery in our case.
The stage of primary tumor and a positive circumferential
resection margin infers an LR risk and poor prognosis.6 Rates
of LR or distant metastases are 5 - 10% in stage A, but 40-70%
in stage C.7 Our patient had a T2N0 tumor with clear radial
margins and no perforation occurred during the surgery. In
addition, the patient had adjuvant radiotherapy and
chemotherapy. As is well known, the CEA level is a useful
marker for follow-up of colorectal cancer recurrence. In our
patient, the CEA level was normal but CA 19.9 level was
increased. Morales-Gutierrez et al also showed in their study
that elevated level of CA 19.9 was an independent risk factor
for recurrence and was associated with a poor prognosis.8 The
surgical treatment of LR is particularly challenging, however
patients with LR have a median survival of approximately 8
months without treatment.9 The 5-year overall survival rate after
the operation for LR is approximately 50% even where surgery
is possible.10 Unfortunately, only a small proportion of patients
with LR have a chance of surgery. These patients are usually
operated via laparotomy ortransanally. But these methods have
their own limitations. In selected patients, the transperineal
approach may be the most easy and appropriate way for
resection of recurrent pelvic lesions. Thus, the difficulties of
laparotomy are avoided. However, adequate preoperative
radiological evaluation must be done. In addition, marking the
lesion is very helpful for the success of the operation in a
transperineal approach. As far as we know, this is the first case
of rectal cancer recurrence treated via the transperineal
approach. Finally, LR is a major cause of morbidity and mortality
in patients undergoing curative resection of rectal cancer.
Surgical resection is the recommended treatment modality and
can be performed safely by the transperineal approach in
selected patients.
MURAT ÖZGÜR KILIÇ1,
GÜRKAN DEGIRMENCIOGLU1,
CENAP DENER1,
NUR ARSLAN2
Correspondence: Dr. Murat Özgür KILIÇ
Department of General Surgery1 and Pathology2,
Faculty of Medicine, Turgut Özal University,
Ankara, Turkey
Email: murat05ozgur@hotmail.com
References
1. Siegel R, Naishadham D, Jemal A.Cancer statistics, 2012. CA
Cancer J Clin. 2012;62:10–29.
2. Rim SH, Seeff L, Ahmed F, King JB, Coughlin SS. Cancer
Colorectal cancer incidence in the United States, 1999–2004: an
updated analysis of data from the National Program of Cancer
Registries and the Surveillance, Epidemiology, and End Results
Program. 2009;115:1967–76.
3. Das P, Skibber JM, Rodriguez-Bigas MA, Feig BW, Chang GJ,
Hoff PM, et al. Clinical and pathologic predictors of locoregional
recurrence, distant metastasis, and overall survival in patients
treated with chemoradiation and mesorectal excision for rectal
cancer. Am J Clin Oncol. 2006;29:219–24.
4. Nissan A, Guillem JG, Paty PB, Douglas Wong W, Minsky B,
Saltz L, et al. Abdominoperineal resection for rectal cancer at a
specialty center. Dis Colon Rectum. 2001;44:27–35
5. Davies M, Harris D, Hirst G, Beynon R, Morgan AR, Carr ND,
et al. Local recurrence after abdomino-perineal resection.
Colorectal Dis. 2009;11:39–43.
6. Kelly SB, Mills SJ, Bradburn DM, Ratcliffe AA, Borowski DW;
Northern Region Colorectal Cancer Audit Group. Effect of the
circumferential resection margin on survival following rectal cancer
surgery. Br J Surg. 2011;98:573–81.
Figure 3: Microscopic appearance of adenocarcinoma with
distortioned tubules in the stroma (HE X 200)
124 Tropical Gastroenterology 2015;36(2):123–125
7. Burdy G, Panis Y, Alves A, Nemeth J, Lavergne-Slove A, Valleur
P. Identifying patients with T3-T4 node negative colon cancer at
high risk of recurrence. Dis Colon Rectum. 2001;44:1682–8.
8. Morales-Gutierrez C, Vegh I, Colina F, Gomez-Camara A,
IgnacioLanda J, Ballesteros D, et al. Survival of patients with
colorectal carcinoma: possible prognostic value of tissular
carbohydrate antigen 19.9 determination. Cancer.
1999;86:1675–81.
9. Moriya Y. Treatment strategy for locally recurrent rectal cancer.
Jpn J Clin Oncol. 2006;36:127–31.
10. Tanaka K, Noura S, Ohue M, Seki Y, Yamada T, Miyashiro I, et
al. Doubling time of carcinoembryonic antigen is a significant
prognostic factor after the surgical resection of locally recurrent
rectal cancer. Dig Surg. 2008;25:319–24.
Blue rubber bleb nevus syndrome –Role of aggressive surgical resection
Introduction
Blue rubber bleb nevus syndrome is a rare multifocal venous
malformation primarily involving the skin, soft tissues and the
gastrointestinal tract but may involve any tissue. We present
the case of a young girl who developed recurrent melena
necessitating surgical resection.
Case report
The patient was a 12-year old girl, a known case of blue
rubberbleb nevus syndrome (BRBNS) who had numerous
lesions (Figure 1) numbering 65, over scalp, lips, trunk,
abdominal wall, all four extremities, gluteal region and vulva
for which she had received four sittings of injection
sclerotherapy (sodium tetradecyl sulphate) with satisfactory
regression of the lesions injected.
She developed intermittent episodes of small volume melena
over the one year prior to presentation, leading to anemia and
chronic fatigue necessitating ten blood transfusions. Blood
pool scan showed no evidence of active intestinal bleed but
showed multiple pooling in the intestine along with numerous
musculoskeletal uptakes.
Wireless capsule endoscopy (Figure 2) revealed multiple
intraluminal blebs from duodenojejunal flexure to the cecum
with no active bleed.
In view of recurrent episodes of melena requiring multiple
blood transfusions, surgery was planned. On examination she
had pallor. Abdominal examination was unremarkable. The
abdomen was accessed through a right upper transverse
Figure 1 Cutaneous manifestation of BRBNS
Figure 2 Capsule endoscopy revealing intraluminal blebs
Tropical Gastroenterology 2015;36(2):125–127
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