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Rectal cancer metastases

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Oleh
Recurrence of colorectal cancer in anastomosis after colectomy can occur due to implantation of cancer cells in the mucosa around the time the anastomosis is performed. This condition can occur on mucosa that has a defect. One of the ceauses of mucosal damage is anal fistula.


Case presentation.
This case discusses perianal cancer that is caused due to metastasis from rectal cancer.

68 year old man with a diagnosis of type 2 rectosigmoid colon cancer. The patient has a history of dextra hemiparesis due to cerebral infarction since 2 months ago. Hemiparesis dextra causes surgery to be delayed for several months so as not to trigger a new infarction.
  • To prevent the progress of cancer, systemic chemotherapy is performed. After 1 month of pre-operative chemotherapy, Hartmann's surgery was performed with lymph node D3 dissection.
  • Surgical specimens show the diagnosis of Dukes B with adenocarcinoma and invasion of the tumor to subserose (T3) without lime or venous infection.
  • Patients also have complaints of perianal abscesses since 5 years ago, but treatment is more focused on cancer first. After 1 month of operation, complaints of abscess worsened and on physical examination found open lesions.
  • Biopsy is performed on an abscess and an adenocarcinoma is obtained.
  • MRI results in tumors, lesions localized perianally. Then a curative resection is performed and the results of the biopsy are found adenocarcinoma results of metastasis from rectal cancer.
  • On immunohistochemistry examination found rectal and anal tumors have the same results, namely cytokeratin 7 (CK7) - and cytokeratin 20 (C20) +.
  • At 31 months follow up there was no recurrence of the tumor after surgery.
Case discussion.
  • The incidence of colorectal cancer metastases to anal fistulas is rare. Damage to the mucosa causes implantation of cancer cells and is followed by proliferation.
  • This study evaluated 24 other cases that had anal to colorectal cancer metastases.
  • The diagnosis from metastasis to anal fistula is made after excluding primary fistula cancer, using hematoxylin-eosin staining or CK7 / CK20 hyunohistochemical examination.
  • Tumor therapy in 21 of 24 cases using curative resection and 7 patients received perioperative chemotherapy.
  • All cases have a good prognosis without recurrence. There is debate as to whether or not concurrent surgery for primary cancer and anal metastatic cancer is better. But researchers prefer to do primary rectal cancer surgery first with the consideration that if anal fistula surgery is also performed it will induce local recurrence due to migration of cancer cells that are exfoliated from primary cancer.
  • Anal tumor surgery must be done carefully to prevent the migration of cancer cells to incision wounds.
  • In that case, the anal tumor is closed with gauze / gauze that is sewn to the skin around the tumor.
  • The prognosis of cases with this advanced stage is not bad, many patients recover without recurrence, especially those without lymphovascular invasion.
  • Cases that are indicative of perioperative adjuvant and neoadjuvant therapy can provide a better prognosis.
Conclusion.
This report discusses the rare cases of anal fistula tumors, the result of metastasis from colon cancer. Colorectal cancer therapy in patients with anal fistula must be done carefully with consideration of the risk of metastasize to the anal fistula.

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