Annals of the Royal College of Surgeons of England (1992) vol. 74, 142-143
Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device David J De Friend
FRCS
Surgical Registrar
John Corson FRCSEd Surgical Registrar
Ellen Kramer BSc MB ChB
Patrick Gallagher
Senior House Officer
Consultant Surgeon
FRCS
Richard Prescott MB ChB Senior Registrar in Pathology Departments of General Surgery and Pathology, Stepping Hill Hospital, Stockport, Cheshire
Key words: Cutaneous seeding; Exfoliated rectal cancer cells; Rectal carcinoma; Circular
stapling
device
We present a case of cutaneous recurrence from an adenocarcinoma of the rectum, which was diagnosed 7 months after anterior resection of the primary tumour had been performed using the EEAO stapling device to fashion the anastomosis. We propose that the recurrence was caused by the seeding of exfoliated tumour cells into an area of perianal skin which was abraded during the introduction of the stapling gun.
Case report A 49-year-old woman underwent radical anterior resection of a carcinoma of the mid-rectum, which was adherent to, but not invading the posterior wall of the vagina. The colorectal anastomosis was performed using the EEA( stapling device, after washout of the distal rectum with chlorhexidine. Histology showed the tumour to be a moderately differentiated Dukes' C adenocarcinoma; the resection margins were clear of tumour. The patient made an uneventful postoperative recovery.
At 7 months postoperatively, she began to complain of pelvic and perianal discomfort and also of prolapsing piles. She was admitted for a sigmoidoscopy and EUA, which revealed a fleshy, broad based tumour growing from the perianal skin, 2 cm from the anal verge (Fig. 1).
Correspondence to: Mr P Gallagher, Department of Surgery, Stepping Hill Hospital, Poplar Grove, Stockport, Cheshire SK2 7JE
Figure 1. Recurrent adenocarcinoma growing in the perianal skin.
evidence of any recurrent or residual the anastomosis or in the rectum. The tumour was locally excised and was found to have an identical histological appearance to the primary carcinoma, suggesting that it had resulted from the seeding of exfoliated tumour cells into the perianal skin at the time of the There
was no
tumour at
anterior resection.
Discussion The potential of exfoliated colorectal carcinoma cells to seed and cause recurrent tumours has aroused considerable interest and debate since first postulated by Sir
Recurrence of rectal carcinoma
Charles Ryall in 1907 to explain some anastomotic recurrences after large bowel resections for cancer (1). In 1978 this hypothesis was challenged by the findings of Rosenberg et al. (2) who found exfoliated colorectal cancer cells to be seldom if ever viable. However, two more recent studies, using more sophisticated tests of cell viability, by Umpleby et al. in 1984 and Skipper et al. in 1987, both showed that a significant number of exfoliated colorectal cancer cells are viable and potentially capable of seeding and growth (3,4). This experimental evidence is backed up by clinical case reports, in which carcinoma deposits associated with proximal colorectal tumours have been described as occurring on haemorrhoidectomy wounds (5), anal fistulas (6), and within the tract of an anal pursestring suture inserted during anterior resection (7). In the case reported here, we feel that the exfoliated tumour cells almost certainly seeded onto an area of skin which was abraded while manipulating the head of the stapling gun into the anal canal. In view of the quite separate routes of lymphatic drainage of the rectum and perianal skin, with an anatomical 'watershed' area at Hilton's white line between them (8), we feel that lymphatic spread is an unlikely explanation even though the primary tumour was Dukes' stage C. Because of the possibility of exfoliation and seeding as a potential route of tumour dissemination, it is common surgical teaching that the distal bowel should be irrigated with a tumoricidal preparation before resection of a colorectal cancer. Some surgeons also advocate isolating the tumour-bearing segment of bowel with occlusive tapes at the start of the procedure. It has been our practice to employ chlorhexidine as a tumoricidal irrigant, but we have now changed to using aqueous povidone-iodine, which was shown by Umpleby and Williamson to be rapidly and effectively tumoricidal in vitro when compared with a number of other commonly used preparations (9).
143
In conclusion, we feel that this case supports the hypothesis of exfoliation and distant seeding as a route of dissemination of colorectal cancers, and re-emphasises the advisability of employing an effective tumoricidal preparation to irrigate the distal bowel at operation. In addition, we recommend that particular care is taken to avoid minor injuries to the skin or mucosa during the peranal introduction of rigid instruments.
References I Ryall C. Cancer infection and cancer recurrence. Lancet 1907;ii: 1311-16. 2 Rosenberg IL, Russell CW, Giles GR. Cell viability studies on the exfoliated colonic cancer cell. BrJ Surg 1978;65:18890. 3 Umpleby HC, Fermor B, Symes MO, Williamson RCN. Viability of exfoliated colorectal carcinoma cells. Br J Surg 1984;71 :659-63. 4 Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and in vitro growth in colorectal cancer. Br 7 Surg 1987;74: 1049-52. S Goligher JC. Surgery of the Anus, Rectum and Colon, 4th Edition. London: Bailliere Tindall, 1980:399-401. 6 Killingback M, Wilson E, Hughes ESR. Anal metastases from carcinoma of the rectum and colon. Aust N Z Jf Surg 1965;34: 178. 7 Bisgaard C, Jensen AS. Iatrogenic cutaneous implantation metastasis from exfoliated rectal adenocarcinoma cells. Acta Chir Scand 1989;155: 137-8. 8 Last RJ. The anal triangle. Anatomy, Regional and Applied. 7th Edition. Edinburgh: Churchill Livingstone, 1984:346-7. 9 Umpleby CH, Williamson RCN. The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl 1984;66: 192-4.
Received 26 7une 1991
Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device David J De Friend
FRCS
Surgical Registrar
John Corson FRCSEd Surgical Registrar
Ellen Kramer BSc MB ChB
Patrick Gallagher
Senior House Officer
Consultant Surgeon
FRCS
Richard Prescott MB ChB Senior Registrar in Pathology Departments of General Surgery and Pathology, Stepping Hill Hospital, Stockport, Cheshire
Key words: Cutaneous seeding; Exfoliated rectal cancer cells; Rectal carcinoma; Circular
stapling
device
We present a case of cutaneous recurrence from an adenocarcinoma of the rectum, which was diagnosed 7 months after anterior resection of the primary tumour had been performed using the EEAO stapling device to fashion the anastomosis. We propose that the recurrence was caused by the seeding of exfoliated tumour cells into an area of perianal skin which was abraded during the introduction of the stapling gun.
Case report A 49-year-old woman underwent radical anterior resection of a carcinoma of the mid-rectum, which was adherent to, but not invading the posterior wall of the vagina. The colorectal anastomosis was performed using the EEA( stapling device, after washout of the distal rectum with chlorhexidine. Histology showed the tumour to be a moderately differentiated Dukes' C adenocarcinoma; the resection margins were clear of tumour. The patient made an uneventful postoperative recovery.
At 7 months postoperatively, she began to complain of pelvic and perianal discomfort and also of prolapsing piles. She was admitted for a sigmoidoscopy and EUA, which revealed a fleshy, broad based tumour growing from the perianal skin, 2 cm from the anal verge (Fig. 1).
Correspondence to: Mr P Gallagher, Department of Surgery, Stepping Hill Hospital, Poplar Grove, Stockport, Cheshire SK2 7JE
Figure 1. Recurrent adenocarcinoma growing in the perianal skin.
evidence of any recurrent or residual the anastomosis or in the rectum. The tumour was locally excised and was found to have an identical histological appearance to the primary carcinoma, suggesting that it had resulted from the seeding of exfoliated tumour cells into the perianal skin at the time of the There
was no
tumour at
anterior resection.
Discussion The potential of exfoliated colorectal carcinoma cells to seed and cause recurrent tumours has aroused considerable interest and debate since first postulated by Sir
Recurrence of rectal carcinoma
Charles Ryall in 1907 to explain some anastomotic recurrences after large bowel resections for cancer (1). In 1978 this hypothesis was challenged by the findings of Rosenberg et al. (2) who found exfoliated colorectal cancer cells to be seldom if ever viable. However, two more recent studies, using more sophisticated tests of cell viability, by Umpleby et al. in 1984 and Skipper et al. in 1987, both showed that a significant number of exfoliated colorectal cancer cells are viable and potentially capable of seeding and growth (3,4). This experimental evidence is backed up by clinical case reports, in which carcinoma deposits associated with proximal colorectal tumours have been described as occurring on haemorrhoidectomy wounds (5), anal fistulas (6), and within the tract of an anal pursestring suture inserted during anterior resection (7). In the case reported here, we feel that the exfoliated tumour cells almost certainly seeded onto an area of skin which was abraded while manipulating the head of the stapling gun into the anal canal. In view of the quite separate routes of lymphatic drainage of the rectum and perianal skin, with an anatomical 'watershed' area at Hilton's white line between them (8), we feel that lymphatic spread is an unlikely explanation even though the primary tumour was Dukes' stage C. Because of the possibility of exfoliation and seeding as a potential route of tumour dissemination, it is common surgical teaching that the distal bowel should be irrigated with a tumoricidal preparation before resection of a colorectal cancer. Some surgeons also advocate isolating the tumour-bearing segment of bowel with occlusive tapes at the start of the procedure. It has been our practice to employ chlorhexidine as a tumoricidal irrigant, but we have now changed to using aqueous povidone-iodine, which was shown by Umpleby and Williamson to be rapidly and effectively tumoricidal in vitro when compared with a number of other commonly used preparations (9).
143
In conclusion, we feel that this case supports the hypothesis of exfoliation and distant seeding as a route of dissemination of colorectal cancers, and re-emphasises the advisability of employing an effective tumoricidal preparation to irrigate the distal bowel at operation. In addition, we recommend that particular care is taken to avoid minor injuries to the skin or mucosa during the peranal introduction of rigid instruments.
References I Ryall C. Cancer infection and cancer recurrence. Lancet 1907;ii: 1311-16. 2 Rosenberg IL, Russell CW, Giles GR. Cell viability studies on the exfoliated colonic cancer cell. BrJ Surg 1978;65:18890. 3 Umpleby HC, Fermor B, Symes MO, Williamson RCN. Viability of exfoliated colorectal carcinoma cells. Br J Surg 1984;71 :659-63. 4 Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and in vitro growth in colorectal cancer. Br 7 Surg 1987;74: 1049-52. S Goligher JC. Surgery of the Anus, Rectum and Colon, 4th Edition. London: Bailliere Tindall, 1980:399-401. 6 Killingback M, Wilson E, Hughes ESR. Anal metastases from carcinoma of the rectum and colon. Aust N Z Jf Surg 1965;34: 178. 7 Bisgaard C, Jensen AS. Iatrogenic cutaneous implantation metastasis from exfoliated rectal adenocarcinoma cells. Acta Chir Scand 1989;155: 137-8. 8 Last RJ. The anal triangle. Anatomy, Regional and Applied. 7th Edition. Edinburgh: Churchill Livingstone, 1984:346-7. 9 Umpleby CH, Williamson RCN. The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl 1984;66: 192-4.
Received 26 7une 1991
