Recurrent Carcinoma of the Colon at the Site of the Anastomosis

Abstract

The occurrence of multiple malignant tumors has always attracted the interest of pathologists and clinicians. The problem consists in determining whether the development of a second growth is entirely independent of the first, unrelated either to metastasis or to recurrence following incomplete eradication. In the case of carcinoma of the colon, a particular type of local recurrence has recently been observed. As pointed out by Cole (1), such a carcinoma, even after ample resection, may recur at the site of anastomosis. Goligher, Dukes, and Bussey (2) have also been impressed with the frequent recurrence of carcinoma—particularly carcinoma of the sigmoid and, to a lesser degree, of the descending colon—at the site of the end-to-end anastomosis. Since we have been unable to find any discussion of this problem as it concerns the roentgenologist, our observations are presented. Case I: S. G., a 68-year-old woman, had a constricting annular mucoid adenocarcinoma of the mid-portion of the descending colon, which was resected in 1949 with sleeves of healthy colon, 17 cm. proximal and 5 cm. distal to the lesion. On a routine re-examination in 1950, small irregularities at the site of the end-to-end anastomosis were noticed. These became more pronounced in 1951 and still more so in 1952. Because of the original resection of a wide portion of healthy tissue and the complete freedom from symptoms, the changes were for a long time considered to be due to the surgical intervention. A local recurrence was suspected only when more irregularity and an annular stricture were observed at an examination three years after the operation (Fig. 1). A penetrating colloid adenocarcinoma at the site of the anastomosis was successfully removed on Jan. 11, 1953. Case II: N. S., a 70-year-old woman, was examined because of massive rectal bleeding. A lobulated pedunculated lesion 2.5 cm. in diameter with a stalk 4 cm. in length was discovered in the mid-sigmoid (Fig. 2A). At operation, Oct. 4, 1950, a segment of the sigmoid, including 5 cm. on either side of the insertion of the polyp, was resected and an end-to-end anastomosis performed. Grossly, the lesion was a pedunculated polyp but histologically the lobulated head was found to be a colloid adenocarcinoma, which did not invade the stalk. Several benign polyps were removed from the rectum. The patient was again seen for rectal bleeding in January 1953. Roentgen examination now revealed an annular, moderately constricting lesion in the mid-sigmoid, apparently about the site of the anastomosis (Fig. 2B). On Jan. 23, another sleeve resection of the sigmoid was performed. The pathologist described the lesion as an adenocarcinoma, recurrent at the site of the earlier anastomosis and spreading to the serosa (Fig. 3). Case III: J. S., a 70-year-old woman, underwent a resection of the sigmoid for an annular carcinoma in July 1952. A recurrence was observed in December 1952, less than six months postoperatively.