Elisabeth C McLemore, MD, Vikram Attaluri, MD, Anna T Tsay, NP, Michele A Fujimoto, MD, Dana Saadat, MC, Rex A Parker, MD, Winston Lien, MD, Aroor Rao, MD. Kaiser Permanente Los Angeles Medical Center
HISTORY: A 60 year old female was found to have recurrent rectal cancer at the site of low pelvic anastomosis approximately 1 year after her initial surgery performed elsewhere. The patient underwent chemoradiation with Xeloda and 4500cGy + 540cGy boost completed in October 2013. During chemoradiation, the patient developed obstructive symptoms and underwent laparoscopic diversion in September 2013. The patient completed the chemoradiation and then underwent low anterior resection with low pelvic anastomosis and diverting ileostomy in December 2013. The pathology revealed ypT3 N1a, 1/13 lymph nodes positive, and negative margins. The quality of the total mesorectal excision, circumferential radial margin, and distal margin distance were not reported. The patient completed eight cycles of FOLFOX in July 2014.
The initial CEA, at the time of diagnosis in July 2013, was elevated (24.4). The CEA reduced during treatment, but never fully normalized after completing tri-modality therapy (CEA 9.2; July 2014). The patient underwent ileostomy reversal without event. Interval clinical staging with cross sectional imaging and endoscopic surveillance was performed. There was no evidence of disease on imaging. However, the digital exam and colonoscopy revealed an anastomotic ulcer and biopsies confirmed the presence of invasive adenocarcinoma consistent with an early local recurrence. The patient was referred to our medical center and underwent further work up with PET / CT. The patient was unable to undergo MRI due to severe anxiety. The lesion was localized to the right posterior lateral anastomotic area without evidence of local extension within 2 cm from the anal verge.
SURGERY: In April 2015, the patient underwent a Robotic translevator abdominal perineal resection with permanent end colostomy. There were no complications, 364 minutes total operative time, 250 mL estimated blood loss, and 5 day hospital length of stay. Final pathology revealed a 4.1×3.2×0.3 cm moderately differentiated adenocarcinoma at the site of the anastomosis, 1.4 cm radial margin, Grade I TME of the residual rectum, 0/7 lymph nodes positive. CEA has returned to normal and the patient is without evidence of disease at this time.
CONCLUSIONS: Recurrent rectal cancer is typically managed with a radical open approach due to the dense pelvic adhesions, local tumor extension, and complexity of the operation. However, in select patients with low lying anastomotic recurrence confined to the rectum, a minimally invasive approach may be feasible.