Asymptomatic Rectal Perforation After Radiation for Rectal Cancer: A Diagnostic Dilemma and Role of MRI

Praveen Kammar,Avanish Saklani,Vikas Ostwal,Suman Kumar Ankati,Prachi Patil,Reena Engineer

doi:10.24983/scitemed.acri.2019.00095

Praveen Kammar, Avanish Saklani + Show 4 more

Open Access

https://doi.org/10.24983/scitemed.acri.2019.00095

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Abstract

Radiation forms a vital part of neoadjuvant treatment in locally advanced rectal cancer (LARC) and recurrent rectal cancers. The adverse effects of radiation are well recognized; however, radiation-induced perforation at the tumour site is very rare and is poorly understood. A symptomatic rectal perforation requires an emergency surgical intervention. However, it may present silently and can give rise to suspicion of disease progression and/or residual disease on imaging. Authors present two cases of silent perforations. Both gave rise to a considerable diagnostic dilemma, which was resolved by careful evaluation with MRI.

Highlights

Radiation forms a vital part of neoadjuvant treatment in locally advanced rectal cancer (LARC) and recurrent rectal cancers
We present two cases of silent perforations. Both gave rise to a considerable diagnostic dilemma, which was resolved by careful evaluation with magnetic resonance imaging (MRI)
MRI of pelvis showed a transmural tumour in the mid-rectum with the involvement of the Circumferential resection margins (CRM), but the vaginal wall appeared free

Summary

Introduction

Radiation forms a vital part of neoadjuvant treatment in locally advanced rectal cancer (LARC) and recurrent rectal cancers. A repeat CT scan done 3 months later showed persistent 5 x 5 cm, well-defined, enhancing, hyperdense mass in the presacral region abutting the posterior wall of rectum (Figures 1 and 2). He was referred to our cancer centre. MRI of pelvis showed a transmural tumour in the mid-rectum with the involvement of the CRM, but the vaginal wall appeared free She underwent short-course radiation (25 Gy, 5 fractions, over 5 days) followed by 4 cycles of chemotherapy with 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX). At 28 months follow-up, the patient is alive with disease

Discussion

Conclusion