Ischiorectal fossa metastasis from colon cancer: Case report of a rare entity and review of literature.

INTRODUCTION AND IMPORTANCE: Colorectal cancer is one of the most common cancers both nationally and internationally. It commonly metastases to local lymph nodes, liver and lungs, with few reported cases of rare sites of metastasis such as adrenal glands, breast and skin. CASE PRESENTATION: We report a 55-year-old-female admitted as case of large bowel obstruction and unintentional weight loss. Computed tomography scan of chest, abdomen and pelvis (CT CAP) showed sigmoid colon circumferential thickening with three lesions in the right hemi-liver. A laparoscopic diverting ileostomy followed by a colonoscopy showed a sigmoidal mass consistent with adenocarcinoma on histopathology. Hence, she received neoadjuvant chemotherapy followed by hepatectomy for the liver metastasis. Post-operatively CT CAP showed a newly developed right ischiorectal fossa (IRF) nodule along with newly developed porta hepatis lymph node. PET scan showed uptake in these two new lesions. Therefore, the patient underwent resection of the primary tumor, porta hepatis lymph node and right ischiorectal fossa nodule excision. The histopathology of the primary tumor came as moderately differentiated adenocarcinoma with both ischiorectal lesion and the porta hepatis nodule being positive for metastatic disease. CLINICAL DISCUSSION & CONCLUSION: Ischiorectal fossa tumors are extremely rare with the majority being benign in origin. Nevertheless, the possibility of metastasis is there with no clear explanation regarding the pathway of how the metastatic cells can reach the IRF. Pre-operative diagnosis is important to determine the appropriate approach particularly if the mass is thought to be malignant. Further larger studies are needed to understand the pathway of metastasis to IRF.

Coloproctology procedure clinic: a novel service developed to reduce suffering of patients with bleeding per rectum.

AIMS: Evaluation of the role and impact of introducing a dedicated coloproctology procedure clinic in tertiary referral colorectal unit. METHODS: A retrospective analysis of 126 consecutive patients managed in the coloproctology clinic between March2015 and September 2016 was carried out. All patients were preselected for attendance based on symptom-based protocol. RESULTS: Based on the information available in GP referrals, 126 patients with bleeding per rectum with low risk of cancer were re-triaged from the general outpatient to dedicated coloproctology procedure clinic. Those patients accounted for 14% of waiting list. The average waiting time to attend clinic was 27 months from referral to undergoing definitive procedure. A proctoscopy or/and rigid sigmoidoscopy was performed in patients. Seventy-nine (89.7%) patients were completely managed and discharged after attending their first visit. Sixty-seven (76%) patients had 2nd- or 3rd-degree haemorrhoids and were treated with rubber band ligation (RBL) or phenol injection in outpatient setting. Two patients had an anal fissure and were managed conservatively with medication. After clinic, follow-up was through telephone clinic. This avoids attendance physically in the hospital. Symptoms persisted in nine patients and were subsequently scheduled for colonoscopy, three had benign polyps. With the introduction of the procedure clinic, the waiting time from referral to treatment was reduced from 27 to 6 months (p < 0.05). CONCLUSIONS: Establishing a dedicated "Coloproctology procedure clinic" is an effective strategy in reducing number of hospital visits per patient and hospital waiting list. This innovative clinic reduces utilisation of precious endoscopy unit resources. This ultimately will improve endoscopy efficiency.

Patterns of thyroid cancer in Southwestern Saudi Arabia.

OBJECTIVE: To examine the pattern of thyroid cancer, assess the magnitude of the problem, and evolve a management plan for such malignancies. METHODS: This is a retrospective cohort study of all thyroid cases operated at Aseer Central Hospital, Abha, Kingdom of Saudi Arabia, between January 1998 and December 2007. Clinical presentations, management regimens, and recurrence were reviewed. RESULTS: Five hundred and sixteen patients were operated for different thyroid lesions. Ninety-two (17.8%) were malignant (20 males and 72 females). Mean age for males was 41.35 +/- 15.52 years compared to 36.59 +/- 13.28 years for females. Papillary carcinoma constituted 50%, while follicular carcinoma formed only 4.3% of malignant cases. Lymphoma ranked third with only 1.1% of all malignant thyroid lesions. No cases of medullary carcinoma were found. Of 92 patients, 75 reported for follow-up. The recurrence rate for follow-up patients was 29 (31.5%). CONCLUSION: High resolution neck ultrasonography and image-guided fine needle aspiration cytology should be considered as routine investigative tools in patients with suspicious thyroid swelling. Total thyroidectomy and removal of all lymph nodes in the central compartment of the neck seem to be the ideal management plan, until such trials emerge. Residual thyroid tissues, following surgery, should be ablated using radioiodine I131 isotope.