Isolated colostomy site recurrence in rectal cancer-two cases with review of literature
© Chintamani et al; licensee BioMed Central Ltd. 2007
Received: 15 October 2006
Accepted: 13 May 2007
Published: 13 May 2007
Colostomy site carcinomas are rare with only eight cases reported in the world literature. Various etiological factors like adenoma-cancer sequence, bile acids, recurrent and persistent physical damage at the colostomy site by faecal matter due to associated stomal stenosis have been considered responsible. Two such cases are being reported and in both cases there was no evidence of any local recurrence in the pelvis or liver and distant metastasis. Both patients had received adjuvant chemotherapy following surgery.
First case was a 30-year-old male that had reported with large bowel obstruction due to an obstructing ulcero-proliferative growth (poorly differentiated adenocarcinoma) at the colostomy site after abdomino-perineal resection, performed for low rectal cancer six years previously. Wide local excision with microscopically free margins was performed with a satisfactory outcome. Four years later he presented with massive malignant ascites, cachexia and multiple liver metastasis and succumbed to his disease.
Second case was a 47-year-old male that presented with acute large bowel obstruction due to an annular growth (well differentiated adenocarcinoma) in the upper rectum. He was managed by Hartmann's operation and the sigmoid colostomy was closed six months later. Five years following closure of colostomy, he presented with two parietal masses at the previous colostomy site scar, which, on fine needle aspiration cytology were found to be well-differentiated adenocarcinomas of colorectal type. Surgery in the form of wide local resection with free margins was performed. He presented again after five years with recurrence along the previous surgery scar and an incisional hernia and was managed by wide local excision along with hernioplasty. Follow-up of nine years following first surgery is satisfactory.
Colostomy site/scar recurrence of rectal carcinoma is rare and could be due to various etiological factors, although the exact causative mechanism is not known. Surgery with microscopically free margins is recommended in the absence of metastatic disease. Stenosis of the stoma is considered as one of the most important contributory factors and should be followed carefully.
Metachronous carcinomas rarely occur at the colostomy site and only eight cases have been reported previously. Various factors like adenoma-cancer sequence, stenosing stoma or bile acids have been implicated. Colon cancer presenting as cutaneous metastasis in an old operative scar has also been reported [1–6]. Possible etiological factors include an alteration in the microscopic anatomy around the scar, perhaps in the lymphatic channels, altered adhesion molecule profile or altered local immunosurveillance mechanisms leading to change in the local environs of the scar which become more receptive to metastatic tumor cells . The occurrence being so rare, no definite etiology and management protocol is known. Management in the form of curative surgery along with adjuvant chemotherapy is recommended.
Postoperative recovery was good and he was discharged on the tenth day. He received the adjuvant chemotherapy in the form of Levamisole and 5 fluorouracil three weekly (total 12 cycles). He was again lost to follow-up and presented subsequently in August 2006 with cachexia, massive malignant ascites, and liver metastasis and succumbed to his disease.
Colon is not an uncommon site for synchronous and metachronous malignancies. The criteria for multiple carcinomas of the colon are well laid out . In a study, multiple carcinomas accounted for 4.3% of all colorectal carcinomas, and for 12.9% of colorectal carcinomas and polypoid cancers of the colon (synchronous 4%; metachronous 2.0%) [6–8].
Cases reported in the literature earlier with two present cases
Year of report
Past history (Age of first surgery in years)
Age at presentation with colostomy site adenocarcinoma(years)
Time of development of carcinoma at the colostomy site
Takami et al. 
19 years after APR
5 years after APR
Nakano et al. 
22 years after APR
Takeyuchi et al. 
12 Year after APR
Ohta et al. 
9 Years after APR
Ishikawa et al. 
30 Years after APR
Ohtsuka et al. 
4 Years after APR
Shibuya et al. 
8 Years after APR
Our patient case-1
Rectal cancer (30)
6 years after APR
Our patient case-2
5 years after LAR
Presence of enterobacteria and bile acids in the stools has also been implicated and reported and the carcinomas occurring at a stoma with which stools were briefly in contact appeared to be rare . Amongst the eight known cases (table 1), three cases including one of the two reported cases may have been affected by bile acids and changes in enterobacteria that resulted from prolonged contact with stools.
There could be a possible similarity in the mechanisms involved in the recurrence at colostomy site to that of recurrence of cancer in a scar of previous surgery and various causative mechanisms have been suggested. There may be a direct extension of the disease, hematogenous spread, lymphatic spread or implantation of exfoliated tumor cells if the specimen had been retrieved through the incision . This is however unlikely to be the scenario in both the presented cases particularly in the first case with recurrence occurring at the site of colostomy. In the second case, the recurrence developed along the scar of previously performed colostomy and this case could possibly resemble in presentation to an incisional scar recurrence in some ways. Predilection to metastasis at incision site has also been postulated to be due to alteration in the microscopic anatomy around the scar, perhaps in the lymphatic channels, making it more receptive to metastatic tumor cells, possibly due to altered adhesion molecule profile or altered local immunosurveillance mechanisms. The exact pathogenesis however remains a matter of speculation awaiting further recognition and investigation [1, 7–10].
Carcinomas may occur coincidentally at a stoma, but the stricture of the stoma and the physical stimulation like regular pressure of tight clothing, could promote their occurrence. The stricture of a stoma should be followed carefully and patient informed about the possibility of development of carcinoma at the colostomy site. When and if detected, surgery with a curative intent (R0 resection) is associated with a good outcome if there are no liver, peritoneal or distant metastases.
Informed consent was obtained from the relative of the first case, and the patient in the second; regarding permission to publish this case in the World Journal Of Surgical Oncology.
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