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Case 18-2004: a 61-Year-Old Man with Rectal Bleeding and a 2-Cm Mass in the Rectum

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Case 18-2004: a 61-Year-Old Man with Rectal Bleeding and a 2-Cm Mass in the Rectum The new england journal of medicine case records of the massachusetts general hospital Founded by Richard C. Cabot Nancy Lee Harris, m.d., Editor Jo-Anne O. Shepard, m.d., Associate Editor Stacey M. Ellender, Assistant Editor Sally H. Ebeling, Assistant Editor Christine C. Peters, Assistant Editor Case 18-2004: A 61-Year-Old Man with Rectal Bleeding and a 2-cm Mass in the Rectum Paul C. Shellito, M.D., Jeffrey W. Clark, M.D., Christopher G. Willett, M.D., and Aaron P. Caplan, M.D. presentation of case From the Department of Surgery (P.C.S.), A 61-year-old man was referred to this hospital for treatment of a low rectal adenocar- the Hematology–Oncology Unit, Depart- cinoma. He had been well until five months previously, when he occasionally began to ment of Medicine (J.W.C.), the Department of Radiation Oncology (C.G.W.), and the note blood in his stool. A stool guaiac test was positive. Three weeks before the patient’s Department of Pathology (A.P.C.), Massa- referral, a colonoscopy was performed at another hospital. A sessile polyp, 10 mm in chusetts General Hospital; and the De- diameter, was removed from the right side of the colon and was determined to be a tu- partments of Surgery (P.C.S.), Medicine (J.W.C.), Radiation Oncology (C.G.W.), bular adenoma; a sessile polyp, 4 mm in diameter, was found 80 cm into the left side of and Pathology (A.P.C.), Harvard Medical the colon; it was excised and found to be associated with a hyperplastic polyp containing School. carcinoma in situ. A friable, sessile lesion, 15 to 20 mm in diameter, was identified very N Engl J Med 2004;350:2500-9. low in the rectum; examination of a biopsy specimen of the lesion disclosed adenocar- Copyright © 2004 Massachusetts Medical Society. cinoma. Nine days later, another colonoscopy was performed with ink injection; biopsy specimens were obtained at the 80-cm site and were found to contain no residual neo- plasm. A polyp, 3 to 4 mm in diameter, was found 110 cm into the colon; it was removed and found to be a tubular adenoma. Computed tomographic (CT) scanning of the abdomen and pelvis performed after the administration of contrast material showed no evidence of metastatic carcinoma. The patient was referred to this hospital. There was a history of mild, intermittent fe- cal incontinence, diabetes mellitus that was controlled with diet, and kidney stones that had been treated by lithotripsy 10 years earlier. He had a 40-pack-year smoking history but had discontinued smoking five years previously. On physical examination, he ap- peared well. An examination of his heart and lungs showed no abnormalities. The pa- tient was moderately obese, and the abdomen was free of palpable masses. During a dig- ital rectal examination, a mobile, soft mass was found low in the left lateral portion of the rectum. Examination by flexible sigmoidoscopy to 20 cm showed a sessile polyp, 0.5 cm in diameter, at 12 cm, and an exophytic, friable mass, 1 by 3 cm, with its lowest edge at 6 cm. The patient sought a second opinion at another hospital. Transanal ultrasound ex- amination at that hospital showed that the mass was either a stage T1 or possibly early stage T2 tumor, and two lymph nodes of normal size were identified in the perirectal area. Another biopsy of the mass was performed at that hospital, and examination of the specimen showed a moderately to poorly differentiated adenocarcinoma. 2500 n engl j med 350;24 www.nejm.org june 10, 2004 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2004 Massachusetts Medical Society. All rights reserved. case records of the massachusetts general hospital The results of laboratory tests, including a com- niques involving the use of rectal coils may enhance plete blood count and measurements of electrolytes, the details of the rectum on MRI scanning. blood urea nitrogen, creatinine, and carcinoembry- Dr. Shellito: This patient was a moderately obese onic antigen, were within normal ranges. A chest man with a small tumor situated very low in the rec- radiograph showed that the lungs were clear, with- tum; he was unusually anxious about his diagnosis out evidence of metastases, and that the cardiac, hi- and treatment and was very determined to avoid a lar, mediastinal pleural, and bony structures were colostomy. Although I frequently refer patients with normal. rectal carcinoma for preoperative radiation and che- motherapy, on initial evaluation this cancer did not discussion of management seem to be locally advanced, so I focused on surgery as the first therapeutic step. The options for surgi- Dr. Paul C. Shellito: Dr. Brugge, will you review the ul- cal treatment of low rectal cancer are abdomino- trasound examinations? perineal resection with a permanent colostomy, low Dr. William Brugge (Gastroenterology): Endoscop- anterior resection with or without the creation of ic ultrasonography is used for the staging of rectal a colon pouch, and local ablation, usually with a cancers according to the tumor–node–metastasis transanal local excision. classification system (Fig. 1A). T1 lesions involve Local excision is the preferred option because it the mucosa with variable invasion into the submu- enables the patient to avoid major surgery and a co- cosa; T2 lesions invade, but do not completely pen- lostomy. The procedure removes just a small por- etrate, the muscularis propria; T3 lesions are trans- tion of the full thickness of the rectal wall, so it is mural and involve all layers of the rectum, including appropriate only for cancers that are less than 2 to the serosa; and T4 lesions involve adjacent struc- 3 cm in diameter and that are limited to the rectal tures, such as the bladder. Ultrasound examination wall and those not accompanied by lymph-node permits visualization of the normal layered structure metastases. The tumor should be mobile on digital of the gastrointestinal tract wall, revealing alternat- rectal examination, exophytic, well or moderately ing black and white bands that correspond to the well differentiated, and located low in the rectum. histologic layers. The muscularis propria appears as Tumors classified as T1 are the best candidates for a thick black band and is our reference point for de- local excision; it is controversial whether or not ex- termining whether the lesion is superficial or in- cision is appropriate for T2 tumors,1-3 since the vades or completely penetrates the muscularis pro- risk of spread to the lymph nodes is higher than it pria. The extent of invasion through the muscularis is with T1 tumors. There is no reliable preopera- propria can be assessed by looking at the outside tive imaging technique for detecting lymph-node border of this layer. A smooth border is indicative metastases. The rate of local recurrence after lo- of a T1 or T2 lesion, whereas an irregular border in- cal excision has ranged from 5 to 20 percent, de- dicates transmural invasion. pending on how carefully patients were selected.3 A transanal endoscopic ultrasonographic exam- About half of such local recurrences can be salvaged ination performed at this hospital (Fig. 1B) shows by radical resection, giving an ultimate long-term an infiltrative mass, 8 mm thick, in the rectum. The survival rate of 80 to 90 percent. This survival rate tumor has invaded the mucosa, submucosa, and compares favorably with that of patients who un- muscularis propria. However, the outside border dergo initial abdominoperineal resection, although of the muscularis propria appears smooth. Several randomized, controlled trials to compare the two lymph nodes are visible, but they are not enlarged approaches are not possible. and have normal echogenicity. Therefore, the lesion I initially considered local excision for this pa- was classified as a T2N0 lesion — one that invades tient because his tumor was small, mobile, and ex- but does not completely penetrate the muscularis ophytic and because of his anxieties about surgery propria, and that is not accompanied by pathologi- and a colostomy. Nevertheless, I changed my mind cally enlarged lymph nodes. when the biopsy specimens from the other hospital Dr. Paul Russell (Surgery): Do you get the same in- were reported to show a moderately to poorly dif- formation from other types of scans? ferentiated tumor. Also, although ultrasound ex- Dr. Brugge: CT and magnetic resonance imaging amination at the other hospital was interpreted as (MRI) scans do not provide nearly the degree of showing only a T1 or perhaps a superficial T2 tu- resolution as ultrasonography. However, new tech- mor, the transanal ultrasound study performed here n engl j med 350;24 www.nejm.org june 10, 2004 2501 The New England Journal of Medicine Downloaded from nejm.org by NASER DARIANI on September 24, 2013. For personal use only. No other uses without permission. Copyright © 2004 Massachusetts Medical Society. All rights reserved. The new england journal of medicine Figure 1. Transanal Ultrasonographic Staging of Rectal Cancer. The tumor–node–metastasis classification system (Panel A) is based on the depth of invasion by a lesion through the layers of the gastrointestinal wall. These layers appear as alternating dark and light bands on an ultrasonogram. In this patient (Panel B), the ultrasonogram shows a mass, 8 mm thick, in the mucosa that extends through the submucosa into the muscularis propria, which is seen as a dark band. The external contour of the muscularis is smooth (arrows), suggesting that the tumor does not infiltrate beyond the muscularis propria. The bright area in the lower part of the field is perirectal fat.
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