Tech Coloproctol (2004) 8:S202–S204 DOI 10.1007/s10151-004-0157-2
D. Tsantilas • A. Ntinas • P. Petras • N. Zambas • S. Al Mogrambi • G. Frangandreas • C. Spyridis T. Gerasimidis
Metachronous colorectal adenocarcinomas
Abstract Background The purpose of our study is to emphasise the diagnostic and therapeutic problems of metachronous colorectal cancer. Materials and methods Between 1990 and February 2004, amongst 185 patients that were treated for colorectal cancer, in four of them a metachronous carcinoma was diagnosed. Results 1st patient: male 41 years, underwent colectomy of the descending colon for adenocarcinoma. Four years later, a rectosigmoidal cancer was found infiltrating urinary bladder. 2nd patient: male 62 years, underwent right hemicolectomy. Eight years later two synchronous cancers were diagnosed, in the left colic flexure and in the sigmoid colon. 3rd patient: female 73 years, underwent low anterior resection for rectal cancer. Eight years later, caecal and ascending colon cancers were diagnosed with hepatic metastases. 4th patient: female 60 years underwent transversectomy. Six years later caecal cancer was diagnosed with pulmonary metastases. Amongst the four
patients, only the fourth had an adequate postoperative follow up. Conclusions Extended radical colectomies in young patients and in those where adenomatous polyps coexist will reduce the incidence of metachronous carcinoma. Effective and persistent postoperative surveillance in patients with colorectal cancer will greatly contribute in the detection and treatment of metachronous carcinomas. Key words Colorectal cancer • Metachronous carcinomas
Introduction Existence of one or more adenocarcinomas in the large intestine, after an initial tumour removing operation, created the concept of synchronous and metachronous colorectal carcinomas. Metachronous cancer can be defined as cancer diagnosed more than 6 months after surgery [1, 2]. With the opportunity of 4 patients that presented metachronous carcinomas of the large intestine and were treated in our department, we will try to define the possible factors that contribute in the appearance of those carcinomas. We will also discuss the diagnostic and therapeutic problems and options and suggest guidelines of prevention according to the recent literature.
Materials and methods D. Tsantilas • A. Ntinas • P. Petras • N. Zambas • S. Al Mogrambi G. Frangandreas • C. Spyridis • T. Gerasimidis () 5th Surgical University Clinic Aristotle University Ippokratio General Peripheral Hospital 49 Kostantinoupoleos Str., 546 42 Thessaloniki, Greece E-mail:
[email protected]
Between 1990 and February 2004, amongst 185 patients that were treated for colorectal cancer, in four of them a metachronous carcinoma was diagnosed. The 1st patient, male 41 years of age, underwent colectomy of the descending colon for adenocarcinoma (C1 Dukes’ stage). Four years later, a rectosigmoidal cancer was found infiltrating urinary bladder. The patient underwent Hartmann’s procedure.
D. Tsantilas et al.: Metachronous colorectal adenocarcinomas
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Discussion
Fig. 1 CT scan. Tumours of the caecum and ascending colon
Fig. 2 CT scan. Pulmonary metastases
The 2nd patient, male 62 years of age, underwent right hemicolectomy for colorectal cancer (stage B2 according to Dukes’ classification), eight years later two synchronous cancers were diagnosed, the first one located in the left colic flexure and the second one in the sigmoid colon. The patient underwent left hemicolectomy. The histopathological examination shows Dukes’ B1 and B2 stage adenocarcinoma respectively. The 3rd patient, female 73 years of age, underwent low anterior resection for rectal cancer (Dukes’ C1 stage). Eight years later, caecal and ascending colon cancers were diagnosed with hepatic metastases (Fig. 1). The patient underwent ileotransverse bypass. The 4th patient, female 60 years of age underwent transversectomy for cancer of the transverse colon (stage Dukes’ C1). Six years later caecal cancer was diagnosed with pulmonary metastases (Fig. 2). The patient underwent right hemicolectomy and the histopathological examination revealed malignant transformation of tubulovillous adenoma (stage A according to Dukes’ staging classification). Amongst the four patients only the fourth had an adequate postoperative follow-up.
Multiple primary carcinomas of the large intestine were reported for the first time by Czerny in 1880 [1]. Their incidence is between 1.5% and 5% of all colorectal carcinomas [2]. That percentage is probably higher considering the fact that not all tumours are discovered either due to diagnostic difficulties or inadequate postoperative follow up. Also some patients are submitted only in palliative operations. It is also known that there is an increased predisposition to develop multiple colorectal cancers in patients with long-standing ulcerative colitis and familial adenomatous polyposis in percentages 18% and 21% respectively [3]. Increased predispositions for metachronous carcinomas also have patients with a family history of colorectal carcinomas and patients with colorectal polyps [4]. In two of our patients we discovered intraoperatively synchronous polyps and in the fourth patient the tumour was a malignant transformation of tubulovillous adenoma stage A according to Dukes’ staging classification. The type of the initial therapeutic operation for the colorectal cancer remains controversial. Some authors [4] propose radical operations such as total colectomy with an ileorectal anastomosis or a restorative proctocolectomy with an ileoanal pouch procedure. The goal is to remove coexisting synchronous tumours and polyps that were misdiagnosed and prevent the future development of metachronous tumours. Other authors [1] suggest conservative operations in older patients and radical in younger patients exactly as happened in our cases. In the past 50 years there has been a shift in the location of carcinomas from the rectum to the right colon. As a result a total colonoscopy is required as a means of postoperative surveillance method every 6 months for the first year and every year thereafter for a minimum period of 8–9 years [2, 5, 6]. Colorectal tumorigenesis is most certainly a disease of the genes, with accumulations of genetic alterations and progressive waves of clonal expansion of cells that have a growth advantage over their progenitors. Different pathways lead to microsatellite instability and malfunction of the genes. Several studies indicate that microsatellite instability can be regarded as a novel independent and important marker for predicting the development of metachronous colorectal carcinoma after surgery [6, 7].
Conclusions Non-radical initial resection and inadequate follow up of patients with colorectal cancer in advanced stages is probably the cause of the presence of metachronous carcinomas. Extended radical colectomies in young patients and
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D. Tsantilas et al.: Metachronous colorectal adenocarcinomas
in those where adenomatous polyps coexist will reduce the incidence of metachronous carcinoma. Effective and persistent postoperative surveillance in patients with colorectal cancer will greatly contribute to the detection and treatment of metachronous carcinomas.
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