Pelvic recurrence after Miles' operation for anastomotic recurrence in a patient with stage I rectal cancer invading the proper muscle layer: Case report

Abstract

We performed D2 low anterior resection in a patient with stage I rectal cancer [pathological diagnosis: proper muscle (pm) invasion, n0, lymphatic invasion (ly), (-); venous invasion (v), (-); anal margin, (-)]. The tumor recurred at the anastomotic site approximately one year later and was treated with Miles' operation [pm, n0, ly (+); v (-); deep border of the primary tumor (-)]. The tumor marker CEA increased to 50.4 ng/ml at four months after surgery and pelvic local recurrence was detected. Since then, the patient has been receiving chemoradiotherapy on an outpatient basis. Cytokeratin immunostaining of all the lymph nodes collected during the two operations showed clusters of occult neoplastic cells (ONCs) in the perinodal fat around the nodes harvested at the first operation. These findings suggest that the risk of local recurrence of rectal cancer is increased even in stage I disease if ONCs are found in the perinodal fat. Further studies are required to examine the relationship between local recurrence and extranodal ONCs in patients with primary rectal cancer.

Stage II/III cancer of the rectosigmoid junction: An independent tumor type?

“…Invasion of adjacent organs, such as the prostate and the vagina is another problem for patients with Rb cancer located on the anterior wall of the lower rectum. Aside from consideration of prophylactic lateral lymph node dissection and laparoscopyassisted colorectal surgery, reports on local recurrence involving the pelvic floor or the anterior surface of the sacrum suggest that this is related to an inadequate resection and extranodal mesorectal spread, which are problems unique to the lower rectal cancer (17,18). Detection of such tumor spread is considered to be extremely difficult by macroscopic examination during surgery or even by pathological examination of intraoperative frozen sections for verification of the resection margin.…”

“…Therefore, it is most important to perform detailed examination of the surgical specimens from patients with Ra/ Rb cancer and lymph node involvement (e.g., by immunohistochemical staining of the mesorectum and surgical margins) and to identify patients with a high risk of recurrence in the early postoperative period (19,20). Patients in the high-risk group need stronger chemoradiotherapy as postoperative adjuvant therapy, additional radiotherapy for the pelvic floor or sacrum, and molecular-targeting agents combined with FOLFOX to control tumor growth (17)(18)(19)(20). Thus, treatment is clearly more complicated for patients with Ra/Rb cancer located deep in the pelvic floor than for patients with RS cancer.…”

Local recurrence and occult neoplastic cells in the extranodal fat of dissected lymph nodes in patients with curatively resected primary colorectal cancer

“…Although the presence of ONCs (single tumor cells) can only be confirmed by immunohistochemical staining, it indicates a high risk of distant metastasis/recurrence for stage I/II N0-local disease after curative resection (2-4). Particularly, ONC clusters (≤10 ONCs) or malignant micro-aggregates (>10 ONCs) are more likely to survive in a new microenvironment and proliferate to cause micro-metastasis and pelvic local recurrence (10)(11)(12)22). Therefore, detection of extranodal ONCs in the fat surrounding dissected lymph nodes is considered to indicate a high risk for local recurrence.…”

“…Therefore, detection of extranodal ONCs in the fat surrounding dissected lymph nodes is considered to indicate a high risk for local recurrence. Low anterior anastomosis should be carefully performed even for stage I rectal cancer when these cells are detected (22).…”

“…The risk factors for postoperative local recurrence of lower rectal cancer include: i) an inadequate resection margin of <2 cm, ii) seeding of cancer cells by iatrogenic bowel perforation or postoperative suture failure, iii) implantation of viable cancer cells in the peritoneal cavity by surgical procedures such as mechanical anastomosis, and iv) unrecognized microscopic tumor extension including undetectable microscopic lymph node metastasis or microscopic tumor deposits in the pelvic fat (13,20,21). With respect to microscopic tumor deposits in the pelvic fat, a recent study showed that cytokeratin-positive ONC clusters can be detected in the perinodal fat around dissected lymph nodes (extranodal ONCs) (22).…”