Multiple Recurrences of Colonic Adenocarcinoma at an Anastomosis Site

Abstract

Purpose: Introduction: Colorectal cancer (CRC) is a common disease which accounts for nine percent of all cancer deaths in the United States. Age is the dominant risk factor for sporadic CRC, with 90% of cases occurring after age 50. Treatment for nonmetastatic CRC is surgical resection, +/− adjuvant chemotherapy and radiation. Despite aggressive regimens, 40% of patients have disease recurrence. However, recurrence at the anastomosis is a rare entity with potential devastating outcome. Case Report: A 67 yo male without prior medical history presents with intermittent rectal bleeding and hemoccult positive stool. Physical exam, CBC, Chem7, LFT: unremarkable. Colonoscopy revealed malignant sigmoid polyp with submucosal venous invasion. Patient underwent left colectomy; pathology notable for a single tumor nodule in pericolic fibroadipose tissue. Postoperative adjuvant chemotherapy was initiated. Patient was asymptomatic for 6 years, with unremarkable surveillance colonoscopies. At 7 years, rising CEA levels triggered a CT abdomen/pelvis, which was notable for soft tissue mass adjacent to descending colon; fine need aspiration was positive for metastatic colonic adenocarcinoma. Patient underwent local resection, chemotherapy and postoperative radiation. Post-operative colonoscopy initially revealed normal appearance of end to side left hemicolectomy of distal sigmoid colon. However, one year later an ulcerated 3cm mass was found at the anastomosis; pathology consistent with colonic adenocarcinoma. Patient underwent a third surgery, left retroperitoneal resection with partial left colectomy. One year after the third surgery, CEA levels rose. At ten years from initial surgery, repeat colonoscopy demonstrated an ulcerated and fungating mass at the anastomosis, consistent with a second anastomosis recurrence. Discussion: CRC ranks as the third most common cancer death in the United States. Despite surgery, chemotherapy and radiation treatment, recurrence rates are as high as 40%. Recurrence at the anastomosis is very rare. Intraluminal anastomosis lesions account for 2-8% of all recurrent tumors; are far more common in rectal versus colonic anastomosis sites, and usually occur by 2.5 years from primary treatment. Our patient presents an unusual case of multiple recurrences at the anastomosis site despite several years of normal surveillance colonoscopies. The importance of monitoring CEA levels, in addition to serial colonoscopies, as a surrogate for tumor burden is highlighted by this case.