© Borgis - Medycyna Rodzinna 1/2014, s. 31-33
Konrad Wroński1, 2, Andrzej Lachowski2, Leszek Frąckowiak1, 3
Jednoczasowa operacja przedniego wycięcia odbytnicy, nefrektomii lewostronnej i wycięcia torbieli jajnika prawego – opis przypadku
Synchronous anterior resection rectal cancer, radical left nefrectomy and right cyst ovary – an unusual case report
1Department of Oncology, Faculty of Medicine, University of Warmia and Mazury in Olsztyn
2Department of Surgical Oncology, Hospital Ministry of Internal Affairs with Warmia and Mazury Oncology Centre in Olsztyn
3Department of Gynecology and Gynecologic Oncology, Hospital Ministry of Internal Affairs with Warmia and Mazury Oncology Centre in Olsztyn
Liczba przypadkowo rozpoznanych niezależnych synchronicznych nowotworów podczas badań obrazowych lub podczas badania klinicznego będzie się stopniowo zwiększać. Jest to trudna sytuacja medyczna, ponieważ nie ma standardów chirurgicznych, w jaki sposób leczyć takich pacjentów. Zachorowalność i umieralność na raka jelita grubego stopniowo wzrasta w Polsce. Podobna sytuacja występuje w przypadku raka nerki, gdzie w ciągu ostatnich dwóch dekad zaobserwowano gwałtowny wzrost nowych przypadków tego raka. W niniejszym artykule autorzy przedstawili przypadek kobiety, która została przyjęta do szpitala z powodu synchronicznego raka odbytnicy, raka nerki i torbieli prawego jajnika. U chorej wykonano jednoczasowe chirurgiczne leczenie raka odbytnicy, raka nerki i torbieli jajnika, a w siódmej dobie po operacji chora została wypisana do domu.
A number of synchronous independent neoplasm incidentally diagnosed on imaging or during clinical examination will be gradually increase. This is difficult medical situation, because there are no surgical management how to treat such patients. Incidence and mortality rates of colorectal cancer have been rapidly increasing in Poland. Similar situation occurs with renal cancer, where in the last two decades have been observed a rapid increase new cases of this cancer. Optimal treatment patients with two or three independent neoplasms is still a matter of debate for several reasons (1-4). First reason: how to treat such patients, and second reason: where such patients should be treated (2, 3, 5-7). The number of patients with two or three independent neoplasms will increase and their optimal treatment is a growing economic problem for health care (7).
A 78-year-old woman, Caucasian race, was admitted to the Department of Surgical Oncology because of diagnosed rectal cancer, left renal tumor and right ovary cyst. The patient suffer from hypertension which was effective treatment and under control. The patient within a month lost about 5 kg. She had no history of alcohol consumption and she was no smoker.
Blood examination tests were normal. On physical examination, abdomen was soft, with no signs of peritoneal. In the Digital Rectal Examination (DRE) about 7 centimeters from the anus, the tumor was palpable. There were no signs of bleeding. Colonoscopy showed rectal tumor 6 centimeters off the anus. Histopatological examination of rectal tumor samples revealed adenocarcinoma. CT examination showed the left renal carcinoma diameter 30 mm (fig. 1), right cyst ovary diameter 80 mm (fig. 2) and rectal carcinoma diameter 70 mm with enlarged lymph nodes size to 20 mm (fig. 3). The patient underwent radiotherapy before surgery.
Fig. 1. CT image showed the left renal carcinoma (diameter 30 mm).
Fig. 2. CT image showed the right cyst ovary (diameter 80 mm).
Fig. 3. CT image showed the rectal carcinoma (diameter 70 mm) with enlarged lymph nodes (size to 20 mm).
The patient was qualified for surgery. After opening the abdomen there were located three pathological tumors revealed in CT examination. As the first the right ovarian cyst was removed (fig. 4). Then performed left nephrectomy (fig. 5) and anterior resection of rectal cancer with total mesorectal excision (fig. 6). The time of surgery was about 200 minutes.
Fig. 4. The right cyst ovary after resection.
Fig. 5. The left renal carcinoma after resection with plentiful fat tissue.
Fig. 6. The rectal carcinoma after anterior resection.
Histopatological examination of postoperative material revealed: renal clear cell carcinoma G2, pT1a and mucinous adenocarcinoma of rectum G3, pT3 with 5 metastases lymph nodes. In another 13 lymph nodes lymphadenitis was discovered. There were no carcinoma cells in right cyst ovary.
Patient after surgery felt good and did not complain of pain. The postoperative period was uncomplicated and the patient left the ward in the seventh day after operation. The patient is in the care of outpatient surgical oncology.
Because of increasing number of ultrasonography examination and CT imaging, the possibility of detection small renal masses and second primary malignant tumor or benign pathology inside the abdomen is probable. Although cancers of the rectum and kidney are common malignancies the incidence of coexistent rectal and renal primary tumors is unclear (4). Synchronous renal carcinoma and colorectal carcinoma is reported from 0.03 to 4.85% cases (1, 2). When surgery is necessary, usually two independent surgical procedures are planned for resection: nephrectomy in urological ward and anterior resection of the rectum in surgical oncology department.
In our case report the period of surgery was 200 minutes and it was longer then normally single open surgical procedure. Blood loss was 300 milliliters. The authors of this article recommend a synchronous surgery for a double tumor of colon and kidney if condition of the patient allow on such procedure. Experience of the surgeons team, time of operation and blood loss probably play a role in avoiding complications and good oncologic results.
Laparoscopic nephrectomy is now the golden standard in urology (8). There are few reports in Pubmed base about simultaneous laparoscopic radical nephrectomy and ipsilateral hemicolectomy (3, 5-7). The authors of the article believe that in the near future, the new gold standard for simultaneous renal and colorectal tumors will be laparoscopy.
Patients with simultaneous kidney cancer and rectal cancer should be treated in highly specialized departments of oncology surgery.
Synchronous lesions may be treated simultaneously without significant morbidity.
Experience of the surgeons team, time of operation and blood loss probably play a role in avoiding complications and good oncologic results.
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