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1130-0108/2012/104/1/41-42
REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
Copyright © 2012 ARÁN EDICIONES, S. L.
REV ESP ENFERM DIG (Madrid)
Vol. 104, N.° 1, pp. 41-42, 2012
Letters to the Editor
Perianal cutaneous metastases from colorectal
adenocarcinoma
Key words: Cutaneous metastases. Exfoliated cancer cells. Colorectal adenocarcinoma.
remains asymptomatic 16 years after its complete removal with
cutaneous adenocarcinoma metastasis diagnosis.
Case 3. An 83 year-old male underwent surgery for rectal villous tumor using a Lone-Star retractor, with diagnosis of an invasive adenocarcinoma. Then, a rectal resection without anastomosis
was done. A year later, a perianal tumor developed and it was
resected, with biopsy of adenocarcinoma (Fig. 1 C). The patient
died two years later of a heart attack, with no evidence of tumor
relapse.
Discussion
Dear Editor,
The appearance of cutaneous metastases in the perianal region
from adenocarcinoma of colon and rectum is an uncommon feature, and its presence usually implies a worse prognosis as a disseminated disease. Occasionally, they present with no evidence
of visceral involvement, therefore their diagnosis and treatment
can significantly modify the course of the disease. We present
3 patients with perianal implants of colorectal cancer treated surgically with good long-term results, emphasizing that in one of
them the implant was discovered before the primary tumor.
Case reports
Case 1. A 54-year-old male presented a hemorrhoidal thrombosis resistant to anti-inflammatory treatment that was biopsied
with the diagnosis of adenocarcinoma. Preoperative tests showed
a sigmoid colon neoplasm with lymphonodes and a small mass
in low rectum-anal canal infiltrating sphincters and puborectalis
muscle (T4 N1 M1) (Fig. 1 A and B). Abdominoperineal amputation was done including the sigmoid tumor and their anal canal
implant. Two years after surgery, the patient is malignancy free.
Case 2. A 55-year-old male who underwent surgery for a welldifferentiated low rectal carcinoma with a coloanal hand-sewn
anastomosis showed a perianal tumor after two years. The patient
The appearance of cutaneous metastasis from colorectal cancer
is an uncommon fact (4%) (1). After tumor diagnosis, the average
interval of the development of implants is 4.9 years, although
they may appear at any time (2).
The most common ways of cutaneous tumor dissemination
are hematic or lymphatic spread. The hypothetical potential of
implant exfoliated tumoral cells, was first time published by
Charles Ryall (3). Subsequently has been demonstrated that exfoliated tumor cells are viable (4), requiring a mucosal damage for
their implantation and growing (5).
In the first patient, some mucosal fraction of his hemorrhoidal
thrombosis was the base of cells implant from a hidden sigmoid
neoplasia. It is the first case described in medical publications.
In the second case, after hand-sewn coloanal anastomosis, the
implant was most likely done during surgery (6). The third
patient’s metastasis appeared probably in the small wounds made
by the Lone-Star retractor used during the tumor resection, like
has been previously published (7).
Implants of malignant cells have been reported on benign anal
lesions during colorectal cancer surgery (2), colonoscopy with
biopsy (8), at the site of laparoscopic ports (1), or even in the
injured perianal area during the introduction of an EEA stapling
device to carry out a mechanical anastomosis (9).
The appearance of perianal metastasis usually implies a worse
prognosis, because it is a disseminated disease with 18-20 months
survival rate (7). However, none of our patients presented recurrence.
42
LETTERS TO THE EDITOR
A
B
REV ESP ENFERM DIG (Madrid)
C
Fig. 1. Perianal implant on a hemorrhoidal thrombosis. A. mucocutaneous erosion (arrows). B. Endoanal ultrasound scan showing a mixed echogenicity
lesion (arrows) infiltrating sphincters at the medium-low anal canal. C. Perianal implant exposed with a Lone-Star retractor prior its resection.
There are several measures to control tumor dissemination
during surgery, although their real effect has not been well proved,
but irrigation of rectal stump with tumoricidal agents before the
anastomosis (10) is recommended.
The perianal cutaneous metastases treatment ranges from limited local resection (1,7,9) to a more aggressive approach (2).
In conclusion, we recommend using preventive measures for
cutaneous implants in colorectal surgery, to rule out an intestinal
origin of a perianal tumor with diagnosis of, and a complete exeresis of perianal implants without evidence of distant disease.
Miriam Cantos-Pallarés, Juan García-Armengol,
Claudia Mulas-Fernández, Cristina Sancho-Moya,
Isabel Fabra-Cabrera, Marcos Bruna-Esteban
and José Vicente Roig-Vila
Unit of Coloproctology. Department of General and Digestive
Surgery. Consorcio Hospital General Universitario
de Valencia. Valencia, Spain
References
1. Placer C, Elósegui JL, Irureta I, Mujika JA, Goena I, Enríquez Navascués
JM. Metástasis cutánea perineal de adenocarcinoma tras cirugía de cáncer
colorrectal. Cir Esp 2007;82:41-3.
2. Kouraklis G, Glinavou A, Kouvaraki M, Raftopoulos J, Karatzas G.
Anal lesion resulting from implantation of viable tumour cells in a preexisting anal fistula. A case report. Acta Chir Belg 2002;102:212-3.
3. Ryall C. Cancer infection and cancer recurrence. Lancet 1907;II:13116.
4. Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and in
vitro growth in colorectal cancer. Br Surg 1987;74:1049-52.
5. 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;94:25862.
6. García-Armengol J, Roig JV, Alós R, Solana A. Metástasis cutánea perianal de adenocarcinoma rectal. Rev Esp Enferm Dig 1995;87:342-3.
7. Tranchart H, Benoist S, Penna C, Julie C, Rougier P, Nordlinger B.
Cutaneous perianal recurrence on the site of Lone Star Retractor after
J-pouch coloanal anastomosis for rectal cancer: report of two cases. Dis
Colon Rectum 2008;51:1850-2.
8. Basha G, Ectors N, Penninckx F, Filez L, Geboes K. Tumor cell implantation with biopsy in a patient with rectal cancer: a case report. Dis Colon
Rectum 1997;40:1508-10.
9. De Friend DJ, Kramer E, Prescott R, Corson J, Gallagher P. Cutaneous
perianal recurrence of cancer after anterior resection using the EEA stapling device. Ann R Coll Surg Engl 1992;74:142-3.
10. Jenner DC, De Boer WB, Clarke G, Lewitt MD. Rectal washout eliminates exfoliated malignant cells. Dis Colon Rectum 1998;41:1432-4.
REV ESP ENFERM DIG 2012; 104 (1): 41-42