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CASE
11
History
For 6 months the patient had noted an increase in
the frequency of bowel function. For this reason the
patient took part in a community bowel screening
program (Hemoccult II) for bowel cancer. The
stools were positive for occult blood. Colonoscopy
revealed a “convoluted bowel”. In “the mid ascending colon” there was a 1.5cm ulcerated lesion,
which on biopsy revealed moderately differentiated adenocarcinoma. A computerized tomography
(CT) scan showed a mass related to the right
colon, extending posteriorly into the psoas muscle
(Figure 11.1). No metastatic disease was detected
in the liver. The patient was referred for surgical
treatment.
Operation (10.9.95)
Through the anterior wall of the cecum a mass was
palpable, fixed to the retroperitoneal tissues. The
appendix formed part of the mass, but only its
proximal 2–3cm was recognizable. There were no
enlarged mesenteric lymph nodes or any metastases
identified. The tumor mass was “dumbbell” shaped,
as illustrated on the CT (Figure 11.1), with the posterior extension deeply penetrating the psoas
muscle. Adequate access to this area was not possible until the colon distally and the ileum proximally
had been transected. Despite this improved access,
Carcinoma of the Appendix
Female, 53 Years
the thin “isthmus” of the “dumbbell” fractured
during dissection so that the deeper part of the
tumor was excised separately from the main specimen. The tumor bed in the psoas muscle was extensively treated with diathermy. An ileo-transverse
colon anastomosis was completed with a circular
stapler.
Pathology
Below the ileocecal valve there was a malignant
ulcer surrounded by a thin rim of friable tumor
which merged with the appendix to form the tumor
mass. Histologically the lesion was a moderately differentiated mucinous adenocarcinoma. The tumor
was seen lining the appendiceal lumen and extending through the wall. “The lumen of the appendix
has been completely blocked: the sections confirm
that it is the primary site” (Figure 11.2). The margin
of tumor clearance of the deep part of the tumor
(within the psoas muscle) was satisfactory. There
were no metastases in 11 mesenteric lymph nodes
examined (Dukes B, T
Follow-Up (2004)
In view of the risk of local recurrence, the patient
was treated with adjuvant chemotherapy (5
Flourouracil and Folinic acid) for 6 months. The
3N0M0
).
Figure 11.1: The CT demonstrates the cecal mass with
posterior extramural extension.
24
Figure 11.2: Adenocarcinoma is shown filling the lumen
of the appendix.
Diagram 11 25
patient remains free of recurrent or metachronous
disease 9 years after operation.
Comment
Although the pathology was thought to be a carcinoma of the cecum at operation, the pathology evidence favors a malignancy developing in a retrocecal
appendix and subsequently ulcerating into the
cecum. Appendiceal carcinoma is rare and it is not
unusual for the diagnosis to be made first by the
pathologist. Nitecki et al studied 94 patients treated
at the Mayo Clinic and found that a correct intraoperative diagnosis was made in only 32% of
1
patients.
The mucinous variety of appendiceal carcinoma occurs in approximately half the appendiceal malignancies (if carcinoids are excluded). Its
spread is to the peritoneum (pseudomyxoma peritonei) rather than to lymph nodes or liver. Increasing depth of local invasion has an adverse effect on
prognosis.
1,2
Dukes B, T3N0M0tumors have been
reported to have a 67%, 5-year survival.1Right
hemicolectomy is the recommended treatment.
1,2
PART
III
Polyps-Polyposis
CASE
12
A Mega Polyp Associated with a Micro Cancer
History
A barium enema was performed in this patient to
investigate the recent onset of constipation, abdominal distention, and weight loss. The x-ray demonstrated a large irregularity of the sigmoid colon and
no other colonic pathology (Figure 12.1). On referral, examination of the abdomen revealed a large
asymptomatic distention of the urinary bladder wall
above the umbilicus. Flexible sigmoidoscopy
revealed a large soft polypoid tumor at 22cm. Urological investigations indicated the need for prostatectomy, which was performed prior to the
colorectal surgery.
Operation (3.2.98)
At laparotomy the only abnormality was the large
soft polyp in the mid sigmoid colon. There was no
Male, 61 Years
obvious enlargement of mesenteric lymph nodes in
relation to the sigmoid colon. The appendix was
markedly kinked by congenital adhesions. The
lower two thirds of the sigmoid colon was resected
with a sutured end-to-end anastomosis. Appendectomy was performed.
Pathology
The polyp extended over 80mm of the sigmoid
colon and “carpeted” the entire circumference of the
lumen, forming a “tube” of polyp tissue. Most of the
lesion was flat, the proximal edge of which merged
with normal colon mucosa. There were raised polypoid areas within the polyp, but, on careful palpation, no firmness in consistency was detected. The
histological examination of the polyp showed a
tubulovillous adenoma with areas of severe dysplasia but no evidence of invasive malignancy. Five
lymph nodes were examined, 1 of which contained
a deposit of metastatic adenocarcinoma, (Figure
12.2) Dukes C, pTNM stage 31(assuming the nodal
metastasis is related to the sigmoid tumor).
Figure 12.1: The barium enema shows the more
proliferative bulk of the sigmoid polyp.
28
Figure 12.2: Deposit of adenocarcinoma in one
mesenteric lymph node.
Diagram 12 29
Follow-Up (2004)
In the past 6 years 2 small benign polyps have been
removed by colonoscopy. There is no evidence of
recurrence of the colon cancer, but the patient developed non-Hodgkin’s lymphoma in 2003, which
appears to have responded to chemotherapy.
Comment
This tumor is an example of “large polyp occult
carcinoma” that showed no evidence of the primary
focus of malignancy on operative, macroscopic, or
microscopic examination. The malignancy was not
identified in the polyp despite the reexamination
of a further 27 blocks of tissue. The incidence of
invasive carcinoma in a polyp is known to be
2
directly related to size,
and, therefore, giant polyps
such as this case can be associated with a high
incidence of carcinoma. Sakamoto et al reported
recurrent malignancy after excision of a “benign”
villous adenoma.3Where possible, these lesions are
best treated by bowel resection as this and Cases 13
and 14 demonstrate.
CASE
13
Extensive “Benign” Polyp of the Rectum and Sigmoid Colon
History
The patient complained of diarrhea for 10 years. Sigmoidoscopy revealed an extensive flat polyp with
polypoid areas which extended from the anal canal
to the lower sigmoid colon, reaching a level of
20cm. There were no obvious features of malignancy. A barium enema showed diverticulosis
proximal to the lesion.
Operation (2.4.77)
Laparotomy and loop transverse colostomy.
Operation (2.18.77)
Via a posterior transsphincteric approach, submucosal dissection removed the tumor from the rectal
muscle. The rectum and sphincter were repaired.
Male, 69 Years
Pathology
Examination of the specimen (23.0 × 18.0cm)
revealed a villous adenoma with no evidence of
malignancy.
Follow-Up
The colostomy was closed 3 months after the
excision of the polyp. A rectal stricture resolved
spontaneously (Figure 13.1). Bowel function was
satisfactory. No abnormality was detected on
regular follow up until March 1986. A presacral
cystic swelling, 11.0 × 7.0 cm, was apparent on computerized tomography (CT) examination of the
pelvis. Transrectal exploration of the cyst produced
a copious discharge of mucus, which on histological
examination contained clusters of mucoid adenocarcinoma cells. Palliative chemotherapy or radiotherapy was decided against. The patient’s health
steadily deteriorated until he died (1.8.87), 10 years
after removal of the “benign” polyp.
Figure 13.1: Complete resolution of postoperative
stricture.
Comment
The extensive lesion would be best classified as a
giant polyp. The surgical options for such a polyp
should be considered differently to those for smaller
Figure 13.2: Free polyp fragments in washings from the
operative field of another patient, also treated with
posterior transsphincteric surgery.
30
Diagram 13 31
flat polyps occurring in the rectum. The treatment
should be based on the probability of invasive carcinoma rather than the technical feasibility of local
excision. The focus of invasive carcinoma in such
polyps may remain undetected despite multiple sections. Galandiuk et al, in reviewing 1049 patients
with villous and tubulo-villous polyps, clearly
demonstrated an increasing incidence of invasive
carcinoma with larger lesions.
1
Polyps larger than 4
cm had a 32% incidence of invasive carcinoma.
One can only speculate the risk of carcinoma in
polyps 10–20cm in size. A number of technically
clever transanal operations are available for local
excision.
2,3
The posterior transsphincteric operation,
first performed by Harrison Cripps in 1880,4was
revived by York Mason in the 1970s, but a review of
this operation has highlighted the unacceptable
complication rate.5The mode of the local recurrence
may have been cell implantation, since the presacral
space was exposed throughout the operation. Figure
13.2 shows the tissue debris in the wound irrigation
fluid from another patient undergoing the same
1
operation for a giant “benign” polyp. This patient
also succumbed to recurrent cancer in the presacral
space. Both patients were fit enough for resection
with coloanal anastomosis.
2.18.77
CASE
14
A Bad Result from a Successful Operation for a Polyp in the Sigmoid Colon
History
The patient presented with a 3-year history of rectal
bleeding and “explosive” diarrhea. Flexible sigmoidoscopy revealed a large polyp at 22cm and 4 small
polyps at lower levels. Colonoscopy identified
4 small polyps between the large lesion and the
splenic flexure.
Operation (3.19.90)
With an operating sigmoidoscope and snare, the
polyp was removed “piecemeal” until a “clean”
mucosal defect was obtained with no visible residual polyp.
Pathology
The polyp fragments were soft, and placed together
they measured 70 × 70mm. Histological examination showed a villous adenoma with no evidence of
malignancy.
Follow Up
The smaller polyps were removed at subsequent
colonoscopy (12.12.91) when the diathermy scar of
the large polyp site was identified. The patient
delayed his next colonoscopy for almost 3 years. At
this time he was asymptomatic. Colonoscopy
revealed an ulcer adjacent to the scar at 22cm
which, on biopsy, showed adenocarcinoma.
Operation (9.16.94)
At laparotomy a large mass of lymph nodes of the
sigmoid mesentery was identified adjacent to the
lower third of the sigmoid colon. There was a 15mm
node at the origin of the inferior mesenteric artery.
Male, 54 Years
Four small metastases (confirmed on biopsy) were
present in the liver. A high anterior resection with
anastomosis was performed.
Pathology
Examination of the lumen of the colon revealed a
malignant ulcer 23mm in diameter at the level of
the lymph node mass and continuous with it. It was
adjacent to but not continuous with the diathermy
scar. The extracolic mass had formed a “dome
shaped” deformity beneath the malignant ulcer.
Histological examination confirmed the diagnosis of
adenocarcinoma (moderately differentiated) with
extensive lymph node involvement.
Follow-Up
The patient was treated with 5 flourouracil and
folinic acid but failed to show any response. He died
of metastatic disease 18 months after the palliative
resection.
Comment
The morphology of the resected lesion was consistent with the lymph node mass having “erupted”
into the lumen of the colon to produce a malignant
ulcer. If so, the apparently benign polyp must have
contained an undiagnosed focus of carcinoma. A
metachronous primary carcinoma at the same site
seems less likely but cannot be excluded. Although
the challenging diathermy snare of a large polyp
at 22cm was a technical success, in hindsight
this patient would have been better managed by
resection.
32
Diagram 14 33
3.19.90
9.16.94