Perforated rectal cancer associated with neoadjuvant radiotherapy: report of four cases

Concurrent rectal perforation and obstruction following neoadjuvant chemoradiation for locally advanced rectal cancer: A case report

INTRODUCTION

Locally advanced rectal cancer (LARC) is commonly managed with neoadjuvant chemoradiation (neoCRT) followed by surgery, though not without complications. The anatomical exposure of the colon and rectum and pelvic radiotherapy poses risk, with rectal perforation and bowel obstruction, though rare, carrying life-threatening potential.

PRESENTATION OF CASE

This case highlights an exceptionally rare occurrence of concurrent rectal perforation and rectal obstruction in a 77-year-old male with LARC, just two months post neoCRT. Initial symptoms included rectal bleeding, and diagnostic procedures confirmed rectal T1N3adenocarcinoma with no metastasis. Emergency admission, prompted by complete bowel obstruction symptoms, led to discovery of rectal perforation during laparotomy, sealed by the bladder. Pathological analysis attributed the cause to radiation proctitis, reporting complete response to neoCRT with no residual tumor.

DISCUSSION

The rarity of both bowel obstruction and perforation as neoCRT complications, particularly in the acute phase of radiation proctitis, is noteworthy in this case. The absence of tumoral cells at the affected sites emphasizes the exceptional nature of this case.

CONCLUSION

This case underscores the importance of recognizing acute post neoCRT injuries as potentially life-threatening complications, emphasizing the need for heightened awareness and consideration in clinical management.

Successful resection of rectal cancer and perirectal abscess following systemic chemotherapy and chemoradiotherapy: A case report

INTRODUCTION AND IMPORTANCE

Perirectal abscesses are uncommon in colorectal cancer. Although abscess infection should be controlled before colorectal cancer treatment, abscess formation makes surgical resection and preoperative treatment difficult. There is currently no established treatment for colorectal cancer with perirectal abscesses. Here, we present a case of rectal cancer with a perirectal abscess that was resected after systemic chemotherapy followed by chemoradiotherapy.

CASE PRESENTATION

A 73-year-old man presented to the outpatient clinic with complaints of weight loss and general malaise. Colonoscopy revealed a circumferential tumor 3 cm from the anal verge, and examination of the endoscopic biopsy specimen indicated a well-differentiated tubular adenocarcinoma. Pelvic magnetic resonance imaging revealed a perirectal abscess on the ventral aspect of the rectum. After sigmoid colostomy was performed to control the infection, 4 cycles of panitumumab and modified fluorouracil, leucovorin, and oxaliplatin were administered. After the perirectal abscess disappeared, chemoradiotherapy to the whole pelvis (radiotherapy 45Gy/25 fractions plus tegafur-gimeracil-oteracil) was administered. Total pelvic exenteration with an ileal conduit was performed via open surgery. The pathological diagnosis was well-differentiated tubular adenocarcinoma with complete resection and negative resection margins. No recurrence of cancer has been observed 26 months after surgery.

CLINICAL DISCUSSION

Treatment of colorectal cancer with perirectal abscess is difficult to define the extent of resection due to the spread of inflammation. We believe that treatment should address high risk of local recurrence.

CONCLUSION

After sigmoid colostomy, complete resection of colorectal cancer with perirectal abscess could be achieved by systemic chemotherapy followed by chemoradiotherapy.

Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality

BACKGROUND

Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality.

METHODS

This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group.

RESULTS

NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001-0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048).

CONCLUSIONS

NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.

Local advanced rectal cancer perforation in the midst of preoperative chemoradiotherapy: A case report and literature review

Standard chemoradiotherapy (CRT) for local advanced rectal cancer (LARC) rarely induce rectal perforation. Here we report a rare case of rectal perforation in a patient with LARC in the midst of preoperative CRT. A 56-year-old male was conveyed to our hospital exhibiting general malaise. Colonoscopy and imaging tests resulted in a clinical diagnosis of LARC with direct invasion to adjacent organs and regional lymphadenopathy. Preoperative 5-fluorouracil-based CRT was started. At 25 d after the start of CRT, the patient developed a typical fever. Computed tomography revealed rectal perforation, and he underwent emergency sigmoid colostomy. At 12 d after the surgery, the remaining CRT was completed according to the original plan. The histopathological findings after radical operation revealed a wide field of tumor necrosis and fibrosis without lymph node metastasis. We share this case as important evidence for the treatment of LARC perforation in the midst of preoperative CRT.

Rectal cancer and Fournier’s gangrene - current knowledge and therapeutic options

Fournier’s gangrene (FG) is a rapid progressive bacterial infection that involves the subcutaneous fascia and part of the deep fascia but spares the muscle in the scrotal, perianal and perineal region. The incidence has increased dramatically, while the reported incidence of rectal cancer-induced FG is unknown but is extremely low. Pathophysiology and clinical presentation of rectal cancer-induced FG per se does not differ from the other causes. Only rectal cancer-specific symptoms before presentation can lead to the diagnosis. The diagnosis of rectal cancer-induced FG should be excluded in every patient with blood on digital rectal examination, when urogenital and dermatological causes are excluded and when fever or sepsis of unknown origin is present with perianal symptomatology. Therapeutic options are more complex than for other forms of FG. First, the causative rectal tumor should be removed. The survival of patients with rectal cancer resection is reported as 100%, while with colostomy it is 80%. The preferred method of rectal resection has not been defined. Second, oncological treatment should be administered but the timing should be adjusted to the resolution of the FG and sometimes for the healing of plastic reconstructive procedures that are commonly needed for the reconstruction of large perineal, scrotal and lower abdominal wall defects.

Is an elective diverting colostomy warranted in patients with an endoscopically obstructing rectal cancer before neoadjuvant chemotherapy?

BACKGROUND

Many surgeons prefer immediate diversion in patients with endoscopically obstructed rectal cancer before starting neoadjuvant chemotherapy.

OBJECTIVE

The aim of this study was to compare immediate neoadjuvant chemoradiotherapy with diversion for endoscopically obstructed rectal cancer.

DESIGN

This study is a retrospective review of patients with rectal adenocarcinoma treated from January 2000 to December 2009. Demographic, tumor, treatment, and outcome data were obtained. Data were analyzed by the use of the Fisher exact probability test and the Student t test.

SETTINGS

This study was conducted at a tertiary care hospital/referral center.

PATIENTS

Included were patients with a rectal adenocarcinoma unable to be traversed endoscopically but without clinical evidence of obstruction before the initiation of neoadjuvant chemoradiotherapy. Patients with recurrent tumors or those who did not complete neoadjuvant chemoradiotherapy because of compliance were excluded.

MAIN OUTCOME MEASURES

The primary outcomes measured were the interval from diagnosis to neoadjuvant chemoradiotherapy initiation and resection and the incidence of complete obstruction.

RESULTS

Eighty-five patients with endoscopically obstructed rectal cancer were identified; 16 underwent immediate diversion before neoadjuvant chemoradiotherapy (diverted group) and 69 were treated with immediate neoadjuvant chemoradiotherapy. Five patients undergoing immediate neoadjuvant chemoradiotherapy presented with bloating and distension; 2 were treated with dietary modification, and 3 (4.3%) progressed to complete obstruction following completion of neoadjuvant chemoradiotherapy and required diversion. Both groups were similar in age, tumor height, and surgical margin status. Patients undergoing diversion required a significantly greater number of permanent stomas and were associated with a higher rate of radical pelvic surgery. There was a significant delay in the initiation of neoadjuvant chemoradiotherapy (p < 0.05) and proctectomy (p < 0.001) from the time of diagnosis in the diverted group compared with the immediate neoadjuvant chemoradiotherapy group. The tumors of patients undergoing diversions were more likely to be unresectable following neoadjuvant chemoradiotherapy.

LIMITATIONS

This study was limited by its retrospective design and possible selection bias.

CONCLUSIONS

Immediate diversion is unnecessary in endoscopically obstructed rectal cancer without clinical signs of obstruction. There appears to be a relationship between immediate diversion and delay in initiation of neoadjuvant chemoradiotherapy and proctectomy. We conclude that immediate neoadjuvant chemoradiotherapy in patients with endoscopically obstructed rectal cancer is safe and feasible.