Hidden local recurrence of colorectal adenocarcinoma diagnosed by endoscopic ultrasound: A case series

INTRODUCTION

In patients with curatively resected colorectal cancer (CRC),local recurrence is often considered a clinical dilemma difficult to treat,may cause markedly disabling symptoms,and usually has a bad prognosis[1,2].Several factors were incriminated in the recurrence as positive surgical margins,especially with inadequate excision,inadequate nodal dissection,implantation of exfoliated malignant cells into the deep layers,and changed biological characters at the site of large bowel anastomosis[3].However,while colonoscopy remains the gold standard method of detecting local recurrences of colorectal cancer (LRCC) and metachronous lesions,it is considered an imperfect tool even in the best hands,with missing rates of adenocarcinoma ranging from 1% to 3%[4,5].Unfortunately,not all local recurrences are detectable at the mucosal surface with false-negative colonoscopy.In these cases,endoscopic ultrasound (EUS) plays an irreplaceable role allowing highly detailed visualization of all the bowel wall layers with all the surrounding structures[6].

The great value of EUS in the evaluation for possible CRC recurrence nowadays comes from its ability to direct fine-needle aspiration (FNA) and fine needle biopsy,thus allowing the acquisition of tissue samples for histological and immunohistochemical examination,and providing a definitive diagnosis.

There are two studies on EUS FNA that showed its high accuracy in the diagnosis of subepithelial and extra-luminal lesions of the colon and rectum[7,8].In both studies,the accuracy of EUS-FNA was 90%-95% compared with an 82% accuracy for imaging alone[8].

CASE PRESENTATION

All patients gave their informed written consent before the procedure.All patients had MRI examination before EUS examination.

All examinations were done under deep sedation with IV propofol.All cases had ano-rectal lesions,maximum 15-20 cm from the anal verge,which are easy to be scanned by the side view scope.No right hemicolon masse were included as they are very difficult to be approached by the side view scope.For EUS-FNA,we used Cook 22G needles (Echotip,Wilson-Cook) (Figure 1).

Chief complaints

: This was a 70-year-old male patient.During LRCC surveillance,no lesions were detected by colonoscopy.The patient experienced unexplained weight loss and was referred for EUS assessment.

: This was a 45-year-old male patient.LRCC surveillance colonoscopy revealed a submucosal lesion at the rectal anastomotic line,and multiple endoscopic biopsies got negative results repeatedly.The patient was referred for EUS examination.

: This was a 45-year-old female patient who presented with difficult defecation.Colonoscopy revealed narrowed rectal anastomotic line,but biopsies were negative.

: This was a 48-year-old male patient.During LRCC surveillance,submucosal elevation at the sigmoido-colonic anastomotic line was noticed by colonoscopy,and endoscopic biopsies showed negative results.

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: This was a 46-year-old male patient.During LRCC surveillance,colonoscopy showed a submucosal lesion with negative endoscopic biopsies.

He took her money in one hand and with the other hand he grasped her mitten7 and said Take me to where you live. I want to see your brother and meet your parents. Let s see if I have the kind of miracle you need.

History of present illness

: EUS was carried out and revealed a 1.2 cm × 2.4 cm homogeneous mass,arising from the fourth layer at the ano-rectal anastomotic line.FNA was performed,and the result confirmed adenocarcinoma.

: The patients underwent LRCC surveillance.

: The patient presented with difficult defecation.

History of past illness

: The patients had a history of CRC surgical excision.

Personal and family history

: No notable personal or family medical history.

Physical examination

The postoperative surveillance of patients treated for CRC is a clinical challenge,first due to distorted anatomy and scarring and second because of intent to prolong survival by diagnosing recurrent and metachronous cancers at a curable stage.LRCC surveillance strategies combined different modalities,including clinical assessment,tumor marker carcinoembryonic antigen,computed tomography (CT) scans,and endoluminal imaging,including colonoscopy,sigmoidoscopy,EUS,and CT colonography.The optimal surveillance strategy is still not clearly defined.

CRC is one of the common and lethal malignancies worldwide and is considered the second leading cause of cancer deaths in the United States[9].Most of CRC patients underwent surgical excision aiming at curative treatment,and up to 40% of patients with the locoregional disease will develop recurrent cancer,of which 90% will occur within 5 years[10,11].

: Unremarkable physical examination.

Laboratory examinations

: No other abnormalities were noted apart from mild microcytic hypochromic anemia.

: No other abnormalities noted.

In the worst of times, creativity and resourcefulness had given us the best of times. I’m now back on my feet financially, and we’ve had many “big” Christmases with lots of presents under the tree…but when asked which Christmas is our favorite, we all remember that one.

Imaging examinations

: EUS assessment revealed a 2.8 cm × 4 cm homogenous mass at the rectal anastomotic line,arising from the fourth wall layer.FNA was performed,and pathological examination confirmed adenocarcinoma.

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: EUS examination showed a 1.9 cm × 2.9 cm homogenous mass,arising from the fourth layer.FNA was performed,and pathological assessment confirmed adenocarcinoma recurrence.

: EUS was conducted and revealed a homogeneous mass measuring 3 cm × 3.3 cm,arising from the fourth layer.FNA was carried out,and adenocarcinoma local recurrence into the deep submucosal layers confirmed.

: EUS revealed a heterogeneous mass measuring 2.3 cm × 4.2 cm arising from the third layer.FNA was performed,and pathological studies confirmed adenocarcinoma recurrence.

The patient experienced unexplained weight loss and was referred for EUS assessment.

FINAL DIAGNOSIS

We report five case series referred to surveillance for LRCC with negative colonoscopy and/or negative endoscopic biopsies.EUS-FNA confirmed LRCC implanted deep into the third and fourth wall layer with normal first and second layer.

TREATMENT

: The patient underwent Lt hemi-colectomy for local recurrence and was referred to medical oncology.

: Partial colectomy was carried out.

: The patient received chemotherapy for cancer colon.

In all cases,the patients were referred to medical cancer institute.

: The patient received chemo-radiotherapy for ano-rectal cancer.

OUTCOME AND FOLLOW-UP

: The patient was referred to medical oncology.

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DISCUSSION

In a moment all the birds in the world seemed flying round his head, and he crumbled9 some of his bread for them and watched them as they darted10 down to pick it up

It was just as if they had all taken something to make them sleepy while they were in the palace, for they did not recover themselves nor speak till they got back again into the street

: Unremarkable apart from unexplained weight loss.

A number of studies have shown EUS to be very accurate in detecting LCRR,with EUS-FNA being able to provide tissue confirmation[12,13].

EUS can act not only as a method for the evaluation of precancerous polyps and subepithelial lesions found during screening of CRC,but also it has a great role in follow-up after resection of rectal carcinoma for early detection and tissue confirmation of locally recurrent cancer colon,by allowing the collection of specimens for histological and immuno-histochemical analysis,and overcoming some of the inherent user bias[18].

Several guidelines and organizations recommend EUS in post-treatment surveillance for resected colon and rectal cancer.The NCCN guidelines state that flexible sigmoidoscopy with EUS or MRI should be done every 3 to 6 mo for 2 years,then every 6 mo to complete 5 years for patients with rectal cancer undergoing transanal excision only[14].The United States Multi-Society Task Force include EUS as an alternative to sigmoidoscopy in the testing strategy for patients at higher risk of recurrence[15].

In patients with a curative resection for rectal cancer,the current US Multi-Society Task Force recommendation suggests EUS at 3-6 mo for the first 2 years after resection as a reasonable option[16].It is noteworthy that not all recurrences are evident at the mucosal surface,so in those cases the benefit of EUS will be restricted in highly detailed visualization and assessment of all the bowel wall layers with all the surrounding structures[6].

Our study showed a rare clinical scenario of hidden implanted adenocarcinoma in the third and fourth layer with an intact mucosal layer,so it was not evident intraluminally and missed by colonoscopy,and endoscopic biopsies were false-negative repeatedly.This may be explained by the presence of cancer cells at the anastomotic line or trapping of cancer cells in the staple line,resulting in local recurrence,especially in patients who underwent double-staplinganastomosis[6,17].

Therefore,EUS-FNA gained the optimal diagnostic procedure and defined the proper treatment plan.

“You poor child,” said the prince and princess; then they praised the crows, and said they were not angry for what they had done, but that it must not happen again, and this time they should be rewarded.

CONCLUSION

Assessment for LCRR is still problematic and may be very tricky,so we recommend using EUS-FNA to exclude local recurrence,since it could be deeply implanted and missed by routine imaging tools and colonoscopy.

Wahba M and Abdellatif AA were involved equally in writing the manuscript;Fontagnier E and Hagag H were involved equally in collecting the data;Elenin SA read and revised the manuscript;Okasha HH revised and approved the final manuscript;all authors have read and approved the final manuscript.

At the wedding ceremony, they hugged each other, and Dr.Stoddard whispered in Mrs. Thompson s ear, Thank you Mrs. Thompson for believing in me, Thank you so much for making me feel important and showing me that I could make a difference.

The study was approved by our institution’s Research Ethical Committee,and all patients gave their informed written consent before inclusion in the study,according to the ethical guidelines of the 1975 Declaration of Helsinki.

All authors declare no competing interests for this article.

So he took it off, and there he stood before her, the handsomest young man she had ever seen in all her life, with short curly yellow hair, and blue eyes, and a laughing face

The authors have read the CARE Checklist (2016),and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

Egypt

I still remember at that time that I said to my husband, Ok, so sir, please choose the time you expect our marriage to last! He said happily, I even do not bother to think about it and would definitely choose 100 years because it is highly money-saving!

: Hussein Hassan Okasha 0000-0002-0815-1394;Mahmoud Wahba 0000-0001-5263-9103;Eva Fontagnier 0000-0001-5746-5480;Abeer Abdellatef 0000-0001-9945-9767;Hani Haggag 0000-0003-4209-1943;Sameh AbouElenin 0000-0002-0633-3004.

This was, in fact, the best time of day in which to approach him, for just now he was pretty sure to be both affable and in good spirits, and for this reason the Grand Vizier Mansor always chose this hour in which to pay his daily visit

Alan woke up at 4:30 on Tuesday for his morning flight to San Francisco. As he kissed our five-year-old daughter Sonali and me good-bye, I pulled him toward me, knocking him over. He laughed heartily4 and said, I ll return with the pot of gold.

Wang LL

Wang TQ

Wang LL

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