Implantation of rectal cancer cells in a fistula in ano: report of a case

Recurrence of sigmoid colon cancer–derived anal metastasis: A case report and review of literature

BACKGROUND

Distant metastasis of colorectal cancer to the anus is very rare, with only 30 related cases published in PubMed thus far. Therefore, recurrence of colorectal cancer derived anus metastases is rarely seen and less presented.

CASE SUMMARY

Here we report an 80-year-old male patient who underwent radical resection for sigmoid colon cancer in January 2010 and another surgery for anal fistula resection in December 2010. Postoperative pathology of the anal fistula revealed a metastatic moderately differentiated adenocarcinoma. The patient subsequently received chemotherapy and radiotherapy. In May 2020, after the patient reported symptoms of anal swelling and pain, computed tomography and magnetic resonance imaging revealed a perianal abscess. Perianal mass biopsy was performed, and the postoperative pathological diagnosis was metastatic moderately differentiated adenocarcinoma.

CONCLUSION

This case highlights that there is a risk of recurrence of anal metastasis of colorectal cancer even after 10 years of follow-up. We also reviewed the literature and discuss potential mechanisms for anal metastasis of colorectal cancer, thus providing some suggestions for treatment of these cases.

A rare case of rectal cancer with perianal metastasis: a case report

Background

Cancer metastasis from colon cancer to an anal fistula is very rare. We herein reported a rare case in which local excision was performed for metastatic anal fistula cancer originating from rectal cancer.

Case presentation

A 68-year-old man was referred to our institution with a diagnosis of rectal cancer. He had complained of anal fistula for 5 years. Based on a recent history of cerebral infarction, Hartmann’s operation was performed to treat the rectal cancer after the administration of preoperative chemotherapy for 3 months. However, 1 month after Hartmann’s operation, the anal fistula was found to have worsened. Pelvic magnetic resonance imaging (MRI) revealed tumor formation at the perianal lesion. Metastatic anal fistula cancer originating from the rectal cancer was diagnosed based on the examination of the biopsied tissue. We selected local excision because the anal tumor had not invaded the surrounding tissue. There has been no recurrence in the 31 months after the curative operation.

Conclusion

Metastatic cancer should be ruled out when treating left-sided colon cancer with anal fistula. Local excision is one possible treatment for metastatic anal fistula cancer.

Perineal skin recurrence on the site of Lone Star Retractor: case report

Background

Local recurrence of colorectal cancer is a major cause of morbidity and mortality that usually implies a worse prognosis. Its etiopathogenesis is still a subject of debate. Recurrence on the perineal wound caused by anal retractor device is rarely reported.

Case presentation

We present the case of a 75-year-old woman with perineal skin recurrence on the site of Lone Star Retractor™ from rectal adenocarcinoma. The patient underwent a curative proctectomy followed by a hand-sewn coloanal anastomosis using Lone Star Retractor™ 2 years ago for a tumor of the lower rectum. The recurrence was most likely caused by the seeding of exfoliated tumor cells into the perianal skin which was abraded by the retractor.

Conclusion

This case is the fourth case reported in the literature and highlights the importance of the use of less traumatic endoanal retractors to prevent such perianal recurrence. Recurrence on the perineal wound caused by anal retractor device is rare but possible. Further studies are needed to define preventive measures able to reduce cutaneous implants.

Synchronous Sigmoid Colon Cancer Seeding a Fistula-in-Ano

A seeded fistula-in-ano from a synchronous sigmoid colon cancer is rare. The literature is still divided regarding the standard treatment, although an abdominoperineal resection is considered the best option when curative resection is possible. This case is distinct from previous reports, as the patient had known metastatic liver disease before surgery, and proceeded with a pan-proctocolectomy after neo-adjuvant chemotherapy. The patient died 20 months post-operatively of his metastatic liver disease, having been otherwise asymptomatic for eight months on continued chemotherapy, before commencing palliative treatment (completed five cycles). Given its rarity, a low suspicion to biopsy a fistula-in-ano is advocated, and the exclusion of malignancy should be considered prior to surgery.

Anal metastasis of rectal cancer-adenocarcinoma of squamous cells: a case report and literature review

Anal metastasis of colorectal cancer is very rare and is usually associated with a history of anal disease, including anal fistula, fissure, hemorrhoidectomy, and anastomotic injury. We report a case of rectal cancer with a synchronous anal metastasis consisting of adenocarcinoma of squamous cells without a history of anal disease. A 60-year-old woman had a chief complaint of melena. She had a 1.5-cm anal tumor on the perianal skin, and a Bollman type 2 rectal tumor on the Ra portion was found on colonoscopy. Biopsy of both tumors revealed a similar histology of well- to moderately differentiated adenocarcinoma. There was no sign of metastases in lymph nodes or other organs. For the purpose of diagnosis and treatment, transperineal local resection of the anal tumor was performed, and it was histologically identified as adenocarcinoma of squamous cells with no invasion to muscles, lymph ducts, or microvessels. The pathological margin was free. Then, to achieve radical cure, laparoscopic low anterior resection (LAR) with D3 lymphadenectomy was performed. The histological diagnosis of the anal tumor was adenocarcinoma of squamous cells without invasion to muscles, lymph ducts, or vessels. The surgical margin was completely free. Immunohistochemical analysis of both tumors revealed similar staining patterns, and the final diagnosis was rectal cancer with metastasis to the anal skin. The patient received no postoperative therapy, and no recurrences have been observed 12 months after surgery. We expect that our sphincter-preserving surgical strategy provided a good prognosis for the synchronous rectal cancer and anal metastasis. This is a rare report of a case with an anal metastasis of colorectal cancer on perianal squamous cells without a history of anal disease that was resected while preserving anal function.

Endoscopic excision of synchronous large bowel polyps in the presence of colorectal carcinoma: is the fear of malignant cell implantation justified? A systematic review of the literature

AIM

A systematic review of the literature was performed to establish evidence to support the practice that in the presence of a colonoscopically diagnosed colorectal cancer immediate endoscopic excision of synchronous polyps should not be performed due to the risk of malignant cell implantation at the polypectomy site.

METHOD

A systematic literature search was performed using Medline, Embase and the Cochrane Central Register of Controlled Trials to identify studies comparing the rate of implantation of colorectal cancer cells in normal and damaged colonic mucosa and reports of colorectal cancer cells seeding into sites of damaged mucosa after polypectomy.

RESULTS

No randomized controlled trials were identified. Three studies involving mammalian models of colonic mucosal damage were included. Pooling relevant results revealed that out of 59 exposed mammals only one developed tumour cell implantation at a site of colonic mucosal damage. This equates to a mammalian in vivo experimental risk of malignant cell implantation of 1.6%.

CONCLUSION

The topic of colorectal cancer seeding following endoscopic procedures has received little attention. This review suggests that in the presence of a proximal colonic carcinoma there is a negligible risk of malignant implantation if a more distal polyp is endoscopically excised.

Primary and secondary adenocarcinomas associated with anal fistulae

PURPOSE

The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae.

METHODS

We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review.

RESULTS

Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer.

CONCLUSION

Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.

Rectosigmoid adenocarcinoma revealed by metastatic anal fistula. The visible part of the iceberg: a report of two cases with literature review

Colonic adenocarcinoma revealed by metastatic anorectal fistula is rare, with few cases in the literature. Such lesions can be taken for the more common manifestation of a benign perianal abscess or fistula. Once diagnosed, the management of such conditions remains controversial. We herein report two cases with perianal fistula that were subsequently found to have developed perianal adenocarcinoma on biopsy. Further colonic investigation revealed a rectosigmoid adenocarcinoma. Histology and immunohistochemical staining was identical in both primary and metastatic tumors. Preoperative chemoradiation with further rectal low anterior resection and local excision of metastatic anal fistula was performed. There is no recurrence after 3 years of follow-up.

Anal metastasis of colorectal carcinoma origin: implications for diagnosis and treatment strategy

BACKGROUND

Anal metastasis originating from colorectal carcinoma is a rare occurrence that severely affects the patient's quality of life. No standardized effective therapeutic strategy exists.

OBJECTIVE

Our aim was to examine clinicopathologic characteristics and outcome of patients with anal metastasis of colorectal origin, directing particular attention to underlying mechanisms of metastasis in relation to potential treatment strategies.

SETTING AND PATIENTS

We identified patients with anal metastasis of colorectal origin by reviewing medical records of patients treated for colorectal cancer in a tertiary teaching hospital in the Osaka region of Japan between 2002 and 2009, and by searching the PubMed and Japanese Ichushi databases for patients reported in the literature.

MAIN OUTCOME MEASURES

Clinical and pathologic variables were examined, including location, depth, and lymph node status of the primary colorectal tumor; mode, timing, site, and symptoms of metastases; as well as treatment and prognosis. The mode of metastasis was classified as either intraluminal or lymphovascular on the basis of clinical history of anal disease and/or histologic analysis of a resected specimen.

RESULTS

Of 851 patients with primary colorectal cancer treated at our institution, 6 patients (0.7%; 95% CI, 0.1-1.3%) had anal metastases, and 38 patients with anal metastases of colorectal origin were identified in the literature; 43 patients could be analyzed. The primary lesion was located in the left colon in all patients. The metastatic mechanism was identified as intraluminal in 35 patients and lymphovascular in 8 patients. Local recurrence after local resection was not reported in any patient with intraluminal metastasis, but was found in 3 patients with lymphovascular metastasis, although all 3 had undergone wide resection.

LIMITATIONS

The study was observational in nature and included a small number of patients.

CONCLUSIONS

Treatment strategies for anal metastasis of colorectal carcinoma origin should consider the mechanism of metastasis. Patients with suspected lymphovascular metastasis should undergo radical resection beyond the primary and metastatic anal tumor to eradicate remnant cancer cells, together with preoperative chemoradiation therapy.

Colosigmoid adenocarcinoma anastomotic recurrence seeding into a transsphincteric fistula-in-ano: a clinical report and literature review

We describe the case of a left colon adenocarcinoma anastomotic recurrence that metastasized to a benign transsphincteric fistula-in-ano, presumably through the implantation of viable malignant cells shed from the secondary tumor, and discuss the implications of these findings in colorectal cancer surgery.

Implantation of Rectal Cancer in an Anal Fistula: Report of a Case

A 53-year-old man who had had an anal fistula for 20 years was admitted to our hospital with a large intestinal obstruction. Barium enema and colonoscopy confirmed advanced rectal cancer and we palpated a soft tumor, 3 cm in diameter, with inflammatory induration on the right side of the rectum. After draining a perianal abscess caused by the anal fistula, we performed low anterior resection. Histological examination of the perianal necrotic tissue obtained during resection of the perianal tumor encompassing the anal fistula revealed adenocarcinoma. Since the histology of the perianal lesion was identical to that of the rectal cancer, a diagnosis of cancer implantation rather than carcinoma originating in the anal fistula was entertained. Although the recurrence of rectal cancer by mucosal implantation is not uncommon, the coincidental implantation of rectal cancer in an anal fistula is extremely rare.

A Case of Rectosigmoid Cancer Metastasizing to a Fistula in ano

We herein report a case of rectosigmoid cancer metastasizing to a fistula in ano. A 53-year-old man complaining of anal bleeding consulted another hospital. He had been suffering from an anal fistula since 7 years. On the left upper side of the skin surface around the anus a fistula end was seen as a hole that tunneled down into the back passage, although no hard tumor was palpable on the hole. Complete colonoscopy revealed an ulcerative tumor in the rectosigmoid colon. On 5 February 2004, anterior resection and lymphadenectomy was performed. The post-operative pathological diagnosis was rectosigmoid cancer, Type 2, T2, N0, M0, stage II. The anal fistula was a simple type and mucinous discharge was not observed. On 23 February 2004, coring out the anal fistula was performed by the former hospital. Pathological diagnosis of the excised fistula revealed well-differentiated adenocarcinoma; identical to the colon tumor. Immunohistochemical staining of these two lesions were negative for (CK) 7 but staining with CK20 revealed some stained tumor cells in two lesions. We diagnosed this tumor as metastatic adenocarcinoma from a rectosigmoid cancer. Recurrent lesions were not seen during the first year after the first operation.

Angiomyofibrosarcoma: a rare ischiorectal fossa swelling

A33-year-old woman presented with a painful lump in the right gluteal region, 7 months after normal vaginal delivery of her child. There was no history of altered bowel habits, bleeding per rectum, dyspareunia or difficult labour. On examination she was afebrile. Local examination revealed asymmetry with a tender lump in the right gluteal region and some redness of the overlying skin. Rectal examination revealed a tender right lateral rectal wall. Magnetic resonance imaging (Figure 1) revealed a 12×8×8 cm complex ‘cyst’ in the right ischiorectal fossa displacing the levator ani upward and the rectum medially, with an apparent pseudo capsule. In the T1-weighted sequences, it had higher signal intensity than the bladder. On T2-weighted sequences, the lesion was of very high intensity. Also in the surrounding fat were multiple linear foci of high intensity, representing oedema or increased vascularity. In view of the location, it was suggested that this could be an abscess.

Examination under anaesthesia revealed a boggy swelling in the ischiorectal fossa. An incision to drain this abscess revealed no pus, however, a soft fatty lump protruded from the incision. The incision was extended and a soft tissue mass 12 cm in diameter was enucleated. The cavity was packed and skin incision closed after 3 days. Histopathology revealed an angiomyxoid tumour, extending to the resection margins. Subsequently she was sent to a specialist centre. Computed tomography of the chest was normal. After discussion with the patient about the possibility of incontinence and stoma, re-excision was performed.

Histology suggested low grade, sarcomatous changes in a pre-existing myofibroblastic lesion, either angiomyxoma or angiomyofibroblastoma. Immunostaining was positive for desmin and weakly positive for actin and calponin. Staining for caldesmin and myogenin were negative. CD34 was present in few scattered spindle cells. No adjuvant therapy was given. She had one admission since then with a wound collection, which was drained.