Intramural metastasis of T1 rectal cancer: report of a case report

Intramural cancer recurrence in the rectum after curative surgery for proximal sigmoid colon cancer: a case report

Background

Intramural metastasis distant from the primary tumor is rare in colorectal cancer. Here, we present a notably rare and probably the first case of asynchronous intramural recurrence in the rectum after curative surgery for proximal sigmoid colon cancer.

Case presentation

A 44-year-old man underwent curative sigmoidectomy for proximal sigmoid colon cancer with T3N0M0, Stage IIA tubular adenocarcinomas. After 15 months, the tumor marker level had increased, and positron emission tomography-computed tomography (PET-CT) revealed abnormal fluorodeoxyglucose uptake in the rectum; colonoscopy revealed a submucosal tumor (SMT)-like lesion in the upper rectum, and biopsy revealed a tubular adenocarcinoma. We performed curative low anterior resection with tumor-specific mesorectal excision (TSME). The SMT-like tumor was located approximately 20 cm from the initial sigmoid colon anastomosis (i.e., at least 20 cm distal to the initial sigmoid colon cancer). The pathological findings revealed cancer cells with the same features as the initial sigmoid colon cancer, only in the intestinal wall but not in the mucosa and extramural tissue. Therefore, the lesion was determined to be an intramural recurrence.

After 24 months, lung recurrence, and local recurrence, which might have involved the lymph nodes in the preserved mesorectum after TSME at the bottom of the pelvis was detected on PET-CT. Hence, we started systemic chemotherapy.

Conclusions

This case report suggests that PET-CT and short-interval repeat colonoscopy may help detect a rare intramural recurrence. A long distal margin may be necessary to achieve local control in the rectal resection for intramural recurrence.

Rectal cancer with extensive distal intramural spread treated by abdominoperineal resection

Distal intramural spread refers to microscopic tumor implantation in the intestinal wall, distal to the inferior edge of a macroscopic tumor but rarely beyond 2 cm. We report a case of rectal cancer with preoperatively diagnosed distant intramural spread to approximately 6.5 cm. A 75-year-old woman diagnosed with upper rectal cancer was scheduled to undergo low anterior resection 5 weeks after initial presentation. However, preoperative digital rectal examination and anoscopy under general anesthesia revealed a rectal tumor 4 cm proximal to the anal verge; adenocarcinoma was diagnosed based on frozen section analysis of the rectal tumor. Therefore, abdominoperineal resection was performed, and histopathological examination confirmed a moderately differentiated adenocarcinoma with distal intramural spread of 6.5 cm. The patient died 18 months postoperatively owing to lung metastasis. Although distal intramural spread is rare and can be difficult to detect prior to surgery, repeated rectal examination, with prompt histological examination of suspicious lesions, can ensure earlier diagnosis to achieve better local control by radical surgery including sufficient distal margin.

Rectal Cancer With Distally Spreading Intramural Metastasis: A Case Report and Review of the Literature

Introduction:

Intramural metastasis (IM) is common in esophageal cancer, and it is an important factor in determining the resection area and tumor malignancy. However, IM is rare in rectal cancer; therefore, little is known about IM in rectal cancer, and the clinical significance remains unclear.

Case Presentation:

We describe a case of rectal cancer with distally spreading IM. A 58-year-old man consulted a primary care physician, with a chief complaint of constipation; tests revealed a high carcinoembryonic antigen value. A colonoscopy revealed a type 2, advanced rectal tumor, which covered two-thirds of the circumference of the upper rectum. In addition, 3 protruding lesions were observed under the normal mucosa on the anal side of the primary tumor. A laparoscopic low anterior resection was performed. Pathologic findings showed that the primary tumor was a moderate-to-well-differentiated adenocarcinoma with a cribriform structure. The 3 lesions on the anal side found under normal mucosa were separate from the primary tumor, but morphologically similar to the primary adenocarcinoma; therefore, these were diagnosed as IMs. Based on a review of previous case reports, rectal carcinomas were often accompanied by vascular invasions and lymph-node metastases. Moreover, in rectal cancer, tumors with IMs often show vascular invasion. Therefore, we assumed that IM could be a marker of poor prognosis.

Conclusion:

This study revealed that, in surgery, detection of a distally spreading IM is an important finding for determining the optimal surgical resection margin.