CT detection of hydronephrosis in resected colorectal cancer: a predictor of recurrent disease

The challenging management of malignant ureteral obstruction: Analysis of a series of 188 cases

Background

Malignant ureteral obstruction (MUO) is a common condition that complicates the course of advanced malignancies. The aims of this study are to analyze the causes, management, and survival of patients with obstructive nephropathy due to malignant ureteric obstruction and to determine prognostic factors. Furthermore, we studied the complications and outcomes in patients who underwent urinary diversion.

Materials and methods

A retrospective study was conducted on patients with computed tomography-confirmed MUO between January 2016 and November 2020. Demographic, clinical, radiological, laboratory, and management data were collected. Survival curves were estimated using the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards models were used to test the association between parameters and survival.

Results

A total of 188 patients were included. The mean age was 69.01 years (SD, 14.95 years), and the majority (54.8%) were male. The most common mechanism leading to MUO was compression by a pelvic mass (36.9%), and the 3 most frequent tumors causing MUO were prostate (17.6%), bladder (16.5%), and rectal cancer (11.7%).Forty-seven patients (25%) underwent urinary diversion: 23 (48.9%) underwent double-J stenting and 21 (44.7%) underwent percutaneous nephrostomy. The most common reason for urinary diversion was acute kidney injury (53.3%). Recovery of renal function was observed in 55.8% of the patients after urinary diversion. The most frequently identified complications after urinary diversion were urinary tract infection (24.4%), hematuria (17.0%), and urinary sepsis (14.9%). The median survival after hydronephrosis diagnosis was 6.43 months (interquartile range, 1.91-14.81 months). In patients who underwent urinary decompression, the median survival after urinary diversion was 8.67 months (interquartile range, 2.99-17.28 months). In the multivariate analysis, a lower grade of hydronephrosis and cancer cachexia negatively impacted survival.

Conclusions

Cancer patients with MUO have a poor prognosis; therefore, the risk-benefit ratio of urinary diversion should be carefully considered. Cachexia and hydronephrosis grade can be useful in selecting suitable candidates for urinary diversion.

Malignant psoas syndrome and bilateral hydronephrosis without evident obstruction in colorectal cancer

Malignant psoas syndrome is a rare and under-recognised entity with a life expectancy of months. Its presentation is characterised by refractory back pain, which is a red flag that should raise suspicion about the condition. We present a case of a man who presented with refractory back pain and bilateral hydronephrosis without hydroureter who had no evident initial obstruction and showed stent-placement failure. Three months later, a recurrence of colorectal cancer associated with malignant psoas syndrome was diagnosed. We review the current literature on malignant psoas syndrome and hydronephrosis in relation to the presentation of cancer.

Treatment efficacy and prognosis analysis in locally advanced or metastatic colorectal cancer patients with hydronephrosis

The effect of hydronephrosis, a common complication of metastatic colorectal cancer (CRC), on the treatment outcome and prognosis of locally advanced or metastatic CRC remains to be elucidated. The present study investigated the clinical characteristics, outcomes, and prognoses of patients with locally advanced or metastatic colorectal cancer (CRC) with hydronephrosis. Clinical data of patients with locally advanced or metastatic CRC who were attending Peking University Shenzhen Hospital and Shenzhen Cancer Hospital between January 2016 and December 2020 were retrospectively collected. A total of 52 patients with hydronephrosis based on CT or MRI findings were selected, and their clinical characteristics, treatment outcomes, and survival times were analyzed. Of the 52 patients, 33 were male (63.5%), and the median age was 49 years (range, 31-76 years). A total of 15 (28.8%) patients with CRC had synchronous hydronephrosis and the remaining 37 patients had metachronous hydronephrosis. Ureters were either compressed by peritoneal or abdominal cavity metastatic lymph nodes in 34 cases (65.4%) or by direct tumor invasion in 18 cases (34.6%). However, objective response rate (ORR) was higher in the group in which ureters were compressed by peritoneal or abdominal cavity metastatic lymph nodes; ORR, disease control rate and median progression-free survival (PFS) between the two groups were not statistically different. (P>0.05). The median survival period was only 27.0 months (95% CI, 20.549-33.451) in patients complicated with malignant hydronephrosis. Univariate and multivariate analyses showed that CA19-9 might be a prognostic factor for locally advanced and metastatic CRC patients with hydronephrosis. Metachronous metastatic CRC has a high incidence rate of complicated hydronephrosis. Targeted drugs in combination with chemotherapy improve the treatment efficacy and prognosis of patients. Notably, the present study found that CA19-9 level might be a prognostic factor in CRC patients with hydronephrosis.

Suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery: a case report

Background

Suture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.

Case presentation

A 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer.

Conclusions

Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection.

Imaging of the Postoperative Colon

Recognition of postoperative complications is important for the immediate diagnosis and treatment needed for appropriate patient care. Identification of postoperative complications from colon surgery requires not only knowledge of the type of procedure, but also the expected normal postoperative appearance. The purpose of this article is to discuss and review the expected anatomic changes after colorectal surgery, and the appearance of the most common postoperative complications.

Local colorectal cancer recurrence: pelvic MRI evaluation

Surveillance of colorectal cancer is currently based on dosage of tumoral markers, colonoscopy and multidetector row computed tomography. However, pelvic magnetic resonance imaging (MRI) and PET-CT are two second-line useful imaging modalities to assess colorectal cancer local recurrence (LR). The anatomical information derived from MRI combined to the functional information provided by diffusion-weighted imaging currently remain of value. Pelvic MRI is accurate not only for detection of pelvic colorectal recurrence but also for the prediction of absence of tumoral invasion in pelvic structures, and it may thus provide a preoperative road map of the recurrence to allow for appropriate surgical planning. As always, correlation of imaging and clinical findings in the multidisciplinary forum is paramount. MRI can also be used to follow-up LR treated with radiofrequency ablation. The aim of this review is to discuss clinical practice and application of MRI in the assessment or pelvic recurrence from colorectal cancer.

CT colonography: surveillance in patients with a history of colorectal cancer

Colorectal cancer is a leading cause of morbidity and mortality in the United States. It is also a disease that is preventable if precursor adenomatous polys are removed. Once a diagnosis of colorectal cancer is made, surgical resection is the only means of cure. The ability to resect colorectal cancer for cure is largely dependent upon the stage of tumor at presentation. Once a patient has been treated for colorectal cancer with surgery and in some cases neo-adjuvant or adjuvant therapy, they will present for follow-up. Surveillance is performed on these patients in order to detect local recurrence that if detected early can be surgically resected for cure. Surveillance also allows detection of distant metastatic disease that may in some cases also be cured with resection. Finally, surveillance of the remaining colon is important to detect the development of new or metachronous adenomatoid polyps that if left in place could develop into new colon cancers. Imaging can play a part in patient surveillance to detect recurrent disease at extracolonic sites as well as the development of new colonic lesions. CT colonography is a promising tool for surveillance in patients with a history of colorectal cancer.

Postoperative anatomic and pathologic findings at CT following colonic resection

CT is frequently used for postoperative evaluation in patients who have undergone colonic resection. This pictorial article reviews and demonstrates the CT findings of normal postoperative anatomic changes, as well as different postoperative complications following various colonic operative techniques.