A rare case of repeated anastomotic recurrence due to tumor implantation after curative surgery for sigmoid colon cancer
© Funahashi et al; licensee BioMed Central Ltd. 2007
Received: 19 March 2007
Accepted: 06 August 2007
Published: 06 August 2007
Anastomotic recurrence is often experienced at colocolic or colorectal anastomoses. Tumor cell implantation has been reported as the mechanism of anastomotic recurrence. However, anastomotic recurrence occurring repeatedly after curative surgery is rare. We herein report a rare case of repeated anastomotic recurrence after curative surgery for sigmoid colon cancer.
A 51-year-old man underwent radical surgery for sigmoid colon cancer. However, anastomotic recurrence developed three times during three years and six months after the initial operation in spite of irrigation with 5% povidone-iodine before anastomosis. The serum carcinoembryonic antigen (CEA) level had been within normal limits after sigmoidectomy. Finally, the patient underwent abdominoperineal resection. The clinico-pathological findings revealed that possible tumor cell implantation caused these anastomotic recurrences. The patients survived without recurrence during the follow-up period of seven years and nine months.
We experienced a rare case of repeated anastomotic recurrence due to possible tumor implantation after curative surgery for sigmoid colon cancer; however the prognosis was ultimately very good. CEA monitoring was insensitive for detection of anastomotic recurrence in this case.
Anastomotic recurrence is likely to develop at colocolic or colorectal anastomoses. The incidence rate is reported at 5–10% [1–3]. However, anastomotic recurrence occurring repeatedly after curative surgery is rare. Here we report a case of anastomotic recurrence that occurred three times within three years and six months after curative surgery of sigmoid colon cancer.
Anastomotic recurrence occurring repeatedly after curative surgery for colorectal cancer is rare. We were unable to find another report like this case, in which anastomotic recurrence had occurred repeatedly after curative surgery. Anastomotic recurrence after curative surgery of colorectal cancer may be due to several causes: implantation of free intraluminal cancer cells on a raw surface or the suture materials; instability of the mucosa at the site of an anastomosis; or positive distal margin of resection [4, 5]. It is difficult to identify the cause of anastomotic recurrence exactly because of the difficulty of early diagnosis. Several researchers have reported tumor cell implantation as the mechanism of anastomotic recurrence [6–8]. In this case tumor cells were not identified histologically at the surgical margins in each of the resected specimens. Also, there was no evidence that the residual tumor cells around the tumor had invaded directly to the anastomotic site intra-operatively. Therefore, implantation of exfoliated malignant cells is suggested as a possible mechanism of anastomotic recurrence in this case. Many researchers have demonstrated that irrigation of the lumen with 5% povidone-iodine is useful to prevent anastomotic recurrence [7–10]. However, we were unable to prevent anastomotic recurrence despite irrigation with 5% povidone-iodine before anastomosis . It is difficult to detect an early anastomotic recurrence. Although analysis of local recurrence in the Stockholm Rectal Cancer Trial revealed that pain was reported as the most dominant symptom, it was not always an early sign of anastomotic recurrence . Although the serum CEA levels considered to be a good predictor for recurrent disease, Moertel et al., reported that CEA testing was most sensitive for hepatic or retroperitoneal metastasis and relatively insensitive for local, pulmonary, or peritoneal involvement . In this case, CEA monitoring was not useful for early detection of anastomotic recurrence. Whichmann et al., also reported that CEA monitoring in which the primary tumor produced no elevation in the serum CEA level, as in this case, was not useful for the early detection of recurrent disease . In this case, colonoscopy was more useful for detecting the patients with occult anastomotic recurrence compared to CEA monitoring. It is now seven years and nine months since the first operation, and there has been no further recurrence. The prognosis of this patient is good, even though anastomotic recurrence occurred repeatedly.
We experienced a rare case of anastomotic recurrence that occurred three times after curative surgery for sigmoid colon cancer, and which we could not prevent by irrigation with 5% povidone-iodine. The prognosis for anastomotic recurrence is good even though anastomotic recurrence occurred three times in this case. Follow-up colonoscopy was helpful for the diagnosis of anastomotic recurrence compared with CEA monitoring.
Written content was obtained from the patient for publication of this report.
- Pihl E, Hughes ES, McDermott FT, Price AB: Recurrence of carcinoma of the colon and rectum at the anastomotic suture line. Sur Gynecol Obstet. 1981, 153: 495-496.Google Scholar
- Stulc JP, Petrelli NJ, Herrera L, Mittelman A: Anastomotic recurrence of adenocarcinoma of the colon. Arch Surg. 1986, 121: 1077-1080.View ArticlePubMedGoogle Scholar
- Umpleby HC, Williamson RC: Anastomotic recurrence in large bowel cancer. Br J Surg. 1987, 74: 873-878. 10.1002/bjs.1800741003.View ArticlePubMedGoogle Scholar
- Roe R, Fermor B, Williamson RC: Proliferative instability and experimental carcinogenesis at colonic anastomoses. Gut. 1987, 28: 808-815.PubMed CentralView ArticlePubMedGoogle Scholar
- McCue JL, Sheffield JP, Uff C, Phillips RK: Experimental carcinogenesis at sutured and sutureless colonic anastomoses. Dis Colon Rectum. 1992, 35: 902-909. 10.1007/BF02047881.View ArticlePubMedGoogle Scholar
- Hubens G, Lafullarde T, Van Marck E, Vermeulen P, Hubens A: Implantation of colon cancer cells on intact and damaged colon mucosa and serosa: an experimental study in the rat. Acta Chir Belg. 1994, 94: 258-262.PubMedGoogle Scholar
- McGregor JR, Galloway DJ, McCulloch P, George WD: Anastomotic suture materials and implantation metastasis: an experimental study. Br J Surg. 1989, 76: 331-334. 10.1002/bjs.1800760405.View ArticlePubMedGoogle Scholar
- Umpleby HC, Fermor B, Symes MO, Williamson RC: Viability of exfoliated colorectal carcinoma cells. Br J Surg. 1984, 71: 659-663. 10.1002/bjs.1800710902.View ArticlePubMedGoogle Scholar
- Sayfan J, Averbuch F, Koltun L, Benyamin N: Effect of rectal stump washout on the presence of free malignant cells in the rectum during anterior resection for rectal cancer. Dis Colon Rectum. 2000, 43: 1710-1712. 10.1007/BF02236855.View ArticlePubMedGoogle Scholar
- Agaba EA: Does rectal washout during anterior resection prevent local tumor recurrence?. Dis Colon Rectum. 2004, 47: 291-296. 10.1007/s10350-003-0046-1.View ArticlePubMedGoogle Scholar
- Terzi C, Unek T, Sagol O, Yilmaz T, Fuzun M, Sokmen S, Ergor G, Kupeliogu A: Is rectal washout necessary in anterior resection for rectal cancer? A prospective clinical study. World J Surg. 2006, 30: 233-241. 10.1007/s00268-005-0300-x.View ArticlePubMedGoogle Scholar
- Holm T, Cedermark B, Rutqvist LE: Local recurrence of rectal adenocarcinoma after 'curative' surgery with and without preoperative radiotherapy. Br J Surg. 1944, 81: 452-455. 10.1002/bjs.1800810344.View ArticleGoogle Scholar
- Moertel CG, Fleming TR, Macdonald JS, Haller DG, Laurie JA, Tangen C: An evaluation of the carcinoembryonic antigen (CEA) test for monitoring patients with resected colon cancer. JAMA. 1993, 270: 943-947. 10.1001/jama.270.8.943.View ArticlePubMedGoogle Scholar
- Wichmann MW, Lau-Werner U, Muller C, Hornung HM, Stieber P, Schildberg FW: Colorectal cancer Study Group. Carcinoembyonic antigen for the detection of recurrent disease following curative resection of colorectal cancer. Anticancer Res. 2000, 20: 4953-4955.PubMedGoogle Scholar
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