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Pelvic exenteration in a patient with locally advanced rectal cancer: Case Report
Apresentação do caso
A 42-year-old male hypertensive patient was seen in January 2017 with abdominal pain for 1 year, associated with enterorrhagia and diarrhea. On physical examination, he presented a tumor 7cm from the anal border, semi-fixed. In the colonoscopy exam, identified an infiltrative and ulcerated lesion that impeded the progression of the device. Biopsy found adenocarcinoma. Staging examinations showed locally advanced disease with no evidence of metastasis. CEA not elevated. He was referred for loop colostomy surgery and neoadjuvant chemotherapy according to Mayo Clinic scheme. During neoadjuvant therapy, he progressed with colostomy prolapse, requiring surgical intervention to correct the prolapse. In June, he underwent total pelvic exenteration with primary end-to-end stapled anastomosis and Bricker urinary reconstruction. On the seventh postoperative day, the patient developed ischemia of the colorectal anastomosis (lowered colon) – resection of the excluded colon and terminal colostomy to Hartmann was performed. The pathological examination showed poorly differentiated residual tubular adenocarcinoma of the rectum, lymph nodes 0/55, ypTpN0, EI and acinar adenocarcinoma of the prostate Gleason 3+3=6, pT2aNX, EIIA, both with free margins. Patient was referred for adjuvant treatment with 5Fluorouracil chemotherapy. Currently in outpatient follow-up, with no disease recurrence.
Locally advanced primary rectal cancer occurs when there is tumor invasion or adherence to local tissues without distant metastase(3,4). Pelvic exenteration (PE) is often the only possibility for complete resection and is considered when a primary rectal cancer has become locally advanced with extension through the rectal wall and mesorectal fascia, invading anteriorly in males into the prostate, seminal vesicles, and/or bladder (3,4). It involves complex radical en bloc resection of all pelvic organs (1,2). It has a significant impact on the patient’s quality of life and high morbidity rate but is the only possibility of cure (5,6).
One of the possible complications of locally advanced rectal cancer is intestinal obstruction, presented by this patient. Once the clearance was performed with loop colostomy, it was possible to perform neoadjuvant chemoradiation and, later, total pelvic exenteration, followed by adjuvant chemotherapy. Although PE is a complex surgery, it's an effective therapeutic option to achieve disease control (patient with no evidence of neoplastic disease to date).
Pelvic exanteration, colorectal neoplasms, locally advanced pelvic cancer
Tumores colorretais e canal anal
BEATRIZ MARTINHÃO HIGA, RENATO MORATO ZANATTO, KARLA THAIZA TOMAL, JUNEA CARIS DE OLIVEIRA, MAURICIO PEREIRA DA SILVA FILHO, VITOR AUGUSTO MELÃO MARTINHO, ANA THEREZA BISSOLI, JUNIOR RODRIGUES SOARES, FLAVIA FERREIRA MAGALINI, EDUARDO MARCUCCI PRACUCHO