A 66-Year-Old Man Presenting with Port-Site Metastatic Gastric Adenocarcinoma 4 Years After Laparoscopic Resection of a Rectal Adenocarcinoma.

BACKGROUND There is a recognized association between synchronous and metachronous colorectal and gastric adenocarcinoma. This report describes a 66-year-old man presenting with port-site metastatic gastric adenocarcinoma 4 years after laparoscopic resection of a rectal adenocarcinoma. CASE REPORT A 66-year-old male rectal cancer survivor presented to the clinic with a painless mass at the previous laparoscopic anterior resection port site. Physical examination revealed a soft port-site mass measuring 5×4 cm. Abdominal CT revealed enlargement of the right rectus abdominis muscle and thickening of the gastric fundus. A biopsy of the right abdominal wall mass revealed metastatic adenocarcinoma. Immunohistochemistry (IHC) testing was positive for cytokeratin 7 (CK7) and CDx2 and negative for cytokeratin 20 (CK20). The possible primary malignancy was upper gastrointestinal, and it was less likely to be colorectal in origin. Subsequently, the upper endoscopy revealed a friable, erythematous gastric mucosa. Biopsy revealed an invasive moderately differentiated gastric adenocarcinoma with positive IHC for CK7 and CDx2 and negative for CK20. The rectal adenocarcinoma pathology slides were reviewed, and IHC testing showed negative CK7 and positive CK20. Patient was known to have multiple comorbidities with poor functional status. The tumor board decision was made to manage him palliatively with best supportive care for the diagnosis of metastatic gastric cancer. CONCLUSIONS This report has presented a case of possible metachronous gastric adenocarcinoma with port-site metastasis following resection of a rectal adenocarcinoma. Clinicians should be aware of the association between synchronous and metachronous colorectal and gastric adenocarcinoma and the challenges associated with the diagnosis.

Isolated Perianal Endometrioma: A Case Report and Literature Review.

BACKGROUND Endometriosis, a common condition among women of reproductive age and infertile women, occurs when the endometrium extends outside the uterus. When this endometrial tissue grows and sheds, symptoms will develop. The presentation varies depending on the site involved; however, cyclical pain is among its most common symptoms, along with bleeding and cramping. It is frequently observed in the ovaries and fallopian tubes; in contrast, the anal canal is rarely involved. Here, we report a very unusual presentation of the disease. CASE REPORT A 33-year-old woman with a history of episiotomy presented to the Emergency Department reporting perianal swelling in the previous year. The swelling was associated with intermittent pain and difficulty passing stool. She reported no fever. On examination, there was a 3×4 cm palpable tender perianal mass extending to the anal sphincter at the 11 o'clock position. Bedside ultrasound revealed a mass. Magnetic resonance imaging showed a hemorrhagic 3×4 cm mass in the right perianal region pressing on and indenting the right aspect of the distal external sphincter. The mass was excised completely with local perianal incision over the mass at 11'o clock. Surgical pathology revealed an isolated endometrioma in the perianal area. CONCLUSIONS Isolated perianal endometrioma is a rare disease, with only 21 published cases. Its diagnosis is difficult to establish, and a wide range of tests is often needed. Laparoscopic or surgical intervention may be required in cases of rectal endometriosis for an accurate diagnosis. Careful history taking and examination along with a high index of suspicion are necessary to diagnose perianal endometrioma.

Cystic Ovarian Leiomyoma in a Patient with Progressive Abdominal Pain.

BACKGROUND Ovarian leiomyomas are rare, benign, smooth muscle, solid tumors that occur in women aged 20 to 65 years. Because their histology is benign, the prognosis for patients is good. We report the case of a patient with a huge ovarian leiomyoma who presented to the General Surgery Clinic with chronic abdominal pain and progressive abdominal distention. CASE REPORT A 45-year-old woman with a history of multiple myomectomies and a total abdominal hysterectomy with right oophorectomy presented to the General Surgery Clinic with abdominal pain and a 4-year history of progressive distention. After being examined, the patient underwent an exploratory laparotomy, during which a pelvic cyst was found that measured 3930.2 cm, was filled with serous fluid (10.5 L), and occupied most of the abdominal space. The surgery went smoothly and there were no complications during or after the procedure. The patient was discharged home 7 days later in stable condition. Postoperative pathology using hematoxylin and eosin staining and immunohistochemistry with desmin and alpha-smooth muscle actin resulted in a diagnosis of leiomyoma with cystic degeneration. When the patient was seen in the outpatient clinic 2 weeks and 3 and 6 months after surgery, her tumor markers were within normal limits. Abdominal and pelvic computed tomography scans performed at the 6-month visit showed resolution of the loculated intraperitoneal fluid and no gross local recurrence of the tumor. CONCLUSIONS Ovarian leiomyomas are difficult to diagnose preoperatively. Suspicion for one should be high, however, in patients who present with a large cystic mass in adnexal tissues, especially if they have a history of hysterectomy and oophorectomy.

Colorectal Schistosomiasis Infection After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Recurrent Metastatic Colon Adenocarcinoma: A Case Report.

BACKGROUND Colorectal cancer is one of the most common cancers in men and women worldwide. There are several studies showing an association between chronic schistosomiasis infection and colorectal cancer. CASE REPORT A 53-year-old woman presented with recurrent metastatic colon cancer involving the peritoneum and bilateral adnexa. The patient then underwent exploratory laparotomy that involved abdominal wall deposit resection, omentectomy, redo left hemicolectomy, peritonectomy, diaphragmatic stripping, and total abdominal hysterectomy with bilateral salpingectomy-oophorectomy, as well as hyperthermic intraperitoneal chemotherapy (HIPEC). She also underwent adjuvant chemotherapy, but on her 6th cycle, the patient suffered intolerable anal pain, diarrhea, and rectal bleeding. Her colonoscopy showed extended circumferential inflammation with loses of vascular pattern and a few rectal ulcers going up to the anastomosis site. Biopsy revealed Schistosoma mansoni eggs and marked ischemic changes. She was then managed with a single dose of Praziquantel. CONCLUSIONS Colorectal schistosomiasis infection is a rare cause of such common presentations especially in postoperative settings in a patient with recurrent metastatic colon cancer. The use of multimodality investigations and high clinical suspicion were needed for the diagnosis and to exclude other common etiologies.

Long-term outcomes after complete mesocolic excision for colon cancer at a tertiary care center in Saudi Arabia.

BACKGROUND: Data on long-term survival and recurrence of cancer after complete mesocolic excision (CME) for colon cancer has not been reported from our center and related to international data. OBJECTIVE: Describe overall and disease-free survival, survival by surgery site and stage, and recurrence rates after curative surgery. DESIGN: Retrospective chart review. SETTINGS: Academic tertiary care center. PATIENTS AND METHODS: The study included all patients who underwent either laparoscopic or open surgery for colon cancer with curative intent between 2001 and 2011. The colorectal database was reviewed for the following: demographic data, comorbidities, radiologic investigations, clinical stage, type of operation, complications, pathologic assessment, adjuvant treatment, recurrence and survival. Survival and recurrence rates were calculated, and survival curves were generated. MAIN OUTCOME MEASURES: 5-year overall survival, secondary endpoints were 5-year disease-free survival, survival by surgery site and stage, and recurrence rates. SAMPLE SIZE: 220. RESULTS: The mean (SD) age at diagnosis was 57 (13) years (CI 95%: 55-59 years). There were 112 males. Mean (SD) body mass index was 27.6 (5.7) kg/m2 (CI 95%: 27-28). Pathological assessment revealed R0 (microscopically margin-negative) resection in 207 (94%). The overall 5-year survival and disease-free survival was 77.9% and 70%, respectively. The 5-year disease-free survival was 69% for the sigmoid/left colon and 69% for the right colon (difference statistically nonsignificant). Stages at the time of resection were stage 0 for 2 (0.01%) patients, stage I for 18 (8%), stage II for 92 (42%), stage III for 100 (46%), and stage IV for 6 (3%). The 5-year overall survival by stages I, II, III and IV was 94%, 80%, 75% and 50%, respectively (difference statistically non-significant). The overall 5-year recurrence rate was 23.4%. CONCLUSION: The outcomes of surgical treatment for colon cancer at our institution are equivalent to international sites. No difference was noted between left and right colon in terms of survival after CME. LIMITATIONS: Single center, retrospective, small sample size. CONFLICT OF INTEREST: None.

Two Histologically Different Primary Malignancies: Synchronous Obstructive Descending Colon Adenocarcinoma and Appendicular Carcinoid Tumor.

BACKGROUND Synchronous primary tumors are defined as 2 or more different histological tumors discovered in one patient at the same time or within a period of 6 months. Colorectal cancer is one of the most common cancers in the United States. Inversely, synchronous colorectal cancer and carcinoid tumors are rare. Carcinoid tumors can be classified into functioning and non-functioning tumors. Carcinoid tumors are steadily increasing in incidence. There is only 1 case reported in the literature as synchronous colorectal cancer and appendicular carcinoid. The difficulty is to manage 2 different types of malignancies at the same time. An optimal medical or chemotherapy strategy is needed. CASE REPORT A 29-year-old woman presented to the emergency room carrying with her computerized tomography (CT) abdomen and pelvic images showing bowel obstruction. Investigations confirmed an obstructing descending colon mass. She underwent colonoscopic stenting as emergency treatment with multiple biopsies. The pathology report came back positive for adenocarcinoma, and we planned to proceed with surgery. Intraoperatively, she was found to have an appendicular mass. The surgical team decided to proceed with laparoscopic-assisted subtotal colectomy. The postoperative course was uneventful, with no complications. The patient was discharged on postoperative day 6 in stable condition. CONCLUSIONS Synchronous colorectal cancer and carcinoid tumors are rare malignancies. The challenge is to find an optimal medical or chemotherapy strategy to manage both malignancies.

A cutaneous metastasis of unresectable rectal adenocarcinoma: A case report and literature review.

BACKGROUND: Colorectal cancer is ranked third among the most commonly diagnosed malignancies and fourth among the leading causes of cancer death in the world. However, only a few case reports are found in the literature regarding skin metastasis originating from rectal cancer, which usually shows widespread disease and poor prognosis. Approximately, 0.8% of the patients will have skin lesion as the first indication of a silent internal malignancy, which is rare. CASE REPORT: We report a complicated case of a 45-year-old male patient who referred to our highly specialized governmental hospital for diversion loop colostomy as well as biopsies of rectal and inguinal skin areas followed by palliative radiation therapy to the pelvis. Histopathological exam of rectal biopsies revealed moderately differentiated rectal adenocarcinoma, while the skin of the right inguinal area showed metastatic cutaneous rectal adenocarcinoma. Unfortunately, palliative radiation therapy was not started as the patient passed away secondary to respiratory failure which ended by cardiopulmonary arrest. CONCLUSION: A patient who is having new or evolving skin lesions with an oncology history should be well investigated as cutaneous metastasis is a strong possibility.

Single-Port Laparoscopic Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is one of the treatment options in low-grade appendiceal mucinous neoplasm with peritoneal dissemination. The minimal invasive surgery approach was introduced to the field after years of traditional open technique. Multi-port laparoscopic and robotic techniques were reported with good short-term outcomes in very selected patients with low PCI scores. We describe here the first single-port laparoscopic approach of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. CASE REPORT We present a case of low-grade appendiceal mucinous neoplasm with peritoneal dissemination, in which single-port laparoscopic approach of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy was completed through a 5.5-cm incision. A 35-year-old man with no medical illness underwent laparoscopic appendectomy for acute appendicitis 3 months earlier. Postoperative surgical pathology reported a low-grade appendiceal mucinous neoplasm with positive margin. After complete assessment and Tumor Board discussion, the patient was scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. A single gel port access was inserted through a 5.5-cm peri-umbilical incision. The Peritoneal Cancer Index score was 4, and the decision was made to proceed with partial cecectomy, omentectomy, peritonectomy, and hyperthermic intraperitoneal chemotherapy with the Sugarbaker mitomycin C-based regimen. Postoperative care was carried out following the Enhanced Recovery After Surgery protocol. The patient was discharged on day 3 without any complications. CONCLUSIONS A single-port laparoscopic approach in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is safe and feasible in very selected patients, and has the advantage of direct visualization and palpation through the incision to determine more accurate Peritoneal Cancer Index assessment in comparison to other MIS approaches. Nevertheless, additional prospective studies are needed.

A Perforated Colonic Neuroendocrine Tumor with Liver Metastasis: A Case Report and Literature Review.

BACKGROUND Neuroendocrine neoplasms (NENs) originate from cells of the endocrine and nervous systems, and they are rarely encountered in colorectal cases with no specific symptoms. The incidence and prevalence of NENs of the large bowel are increasing. Malignant colonic types are known to have poor diagnosis. The mean age of colonic NENs is the seventh decade, and the risk of NENs is increased 4-fold with affected first-degree family members. CASE REPORT A 57-year-old male patient presented to our Emergency Department with a 5-day history of severe generalized abdominal pain associated with worsening abdominal distension, history of night sweats, and weight loss. A CT scan of the abdomen and pelvis demonstrated a large heterogeneously enhancing neoplastic mass lesion involving the splenic flexure of the colon surrounded by fat stranding with a small contained leak, in addition to multiple metastatic hypodense focal hepatic lesions. Multiple lymph nodes under 1 cm in size were also noted. The patient underwent exploratory laparotomy, subtotal colectomy, ileostomy creation, and washout. The histopathological exam revealed high-grade invasive colonic neuroendocrine carcinoma, which was pT4N2bM1c, while the peritoneal lesion was metastatic carcinoma. The patient was then referred to the multidisciplinary tumor board. CONCLUSIONS Unusual presentation of neuroendocrine tumors is shown to be expected. Since colorectal NECs are rare, highly aggressive diseases and usually discovered very late, individualization of management, as well as additional research, is required.

Survival and outcomes after laparoscopic versus open curative resection for colon cancer.

BACKGROUND: Many studies have shown that open and laparoscopicsurgery for resection of colonic cancers produce similar short- and long-term results, but no data have been reported from Saudi Arabia. OBJECTIVE: Compare 3-year disease-free and overall survival after laparoscopic versus open curative resection for potentially curable colon cancer. DESIGN: Multicenter retrospective cohort study. SETTING: Tertiary academic hospital. PATIENTS AND METHODS: We analyzed data of patients who underwent curative resection for potentially curable colon cancer using the laparoscopic or open approach at three tertiary care centers during the period 2000-2015. MAIN OUTCOME MEASURES: Overall and disease-free 3-year survival were the primary endpoints. Secondary endpoints included conversion rate, duration of surgery, length of hospital stay, rate of wound infection, resumption of bowel function, number of lymph nodes retrieved, adequacy of resection and rate of recurrence. Risk factors for recurrence, including complete mesocolic excision, were assessed. SAMPLE SIZE: 721. RESULTS: Patient and tumor characteristics were similar in the two groups except for ASA class ( P<.01), weight ( P<.05) and tumor stage ( P<.05). Over a median follow-up of 46 months, the 3-year overall survival was 76.7% for open resection and 90.3% for laparoscopic colon resection ( P<.05). The 3-year disease-free survival was 55.3% for open colon resection and 64.9% for laparoscopic colon resection ( P=.0714). CONCLUSION: Overall and disease-free survival after the laparoscopic approach for curative resection of colon cancer is comparable to the open approach. LIMITATIONS: Retrospective design and the possibility of selection bias. CONFLICT OF INTEREST: None.