*Antonina Respondek-Bartuś, Natalia Dziewa, Radosław Cylke
Proctology Patients with Oncology and Immune Deficiency – A Case Report
Pacjenci proktologiczni z chorobą onkologiczną i deficytem odporności immunologicznej – opis trzech przypadków
Department of General and Transplant Surgery, Infant Jesus Hospital, University Clinical Center, Medical University of Warsaw
Streszczenie
Pacjenci z obniżoną odpornością stanowią coraz liczniejszą grupę w społeczeństwie. Są to najczęściej osoby z rozpoznaniem nowotworu, głównie w trakcie chemioterapii, pacjenci leczeni biologicznie z powodu nieswoistych chorób jelit czy też po przeszczepieniu narządów przyjmujący na stałe leki immunosupresyjne, a także osoby z nabytym zespołem obniżonej odporności w przebiegu zakażenia wirusem HIV.
Szacuje się, że aż 30% pacjentów onkologicznych dotkniętych jest chorobą proktologiczną. Dolegliwości proktologiczne mogą być bezpośrednio związane z lokalizacją choroby nowotworowej (np. naciekający guz kanału odbytu lub odbytnicy), jednakże częściej choroba proktologiczna jest wynikiem spadku odporności u pacjenta po leczeniu onkologicznym (ropień i/lub przetoka odbytu).
Wskazania do leczenia chirurgicznego są wówczas ograniczone z uwagi na obniżoną odporność (neutropenia), a także zaburzenia funkcji układu krzepnięcia (w tym często zaburzenia funkcji płytek).
Wybierając metodę leczenia u tego typu pacjentów, należy mieć na uwadze kilka ważnych aspektów. Do najważniejszych należą możliwość równoczesnego prowadzenia leczenia onkologicznego oraz aktualny stan odporności immunologicznej pacjenta.
Autorzy przedstawią przypadki czterech pacjentów proktologicznych z defektem immunologicznym, na tle których szerzej omówią zagadnienie leczenia tej specyficznej grupy pacjentów.
Summary
Patients with immunocompromised immune systems constitute a growing group in society. These include those diagnosed with cancer, primarily those undergoing chemotherapy, patients receiving biological therapy for inflammatory bowel disease, or those receiving long-term immunosuppressive medications after organ transplantation, as well as individuals with acquired immunodeficiency syndrome due to HIV infection.
It is estimated that as many as 30% of cancer patients are affected by proctology. Proctological symptoms may be directly related to the location of the cancer (e.g., an infiltrating tumor of the anal canal or rectum). However, proctological disease is more often the result of a weakened immune system in a patient after cancer treatment (anal abscess and/or fistula).
Indications for surgical treatment are then limited due to reduced immunity (neutropenia) and impaired coagulation function (often including platelet dysfunction).
When choosing a treatment method for these patients, several important aspects should be considered. The most important include the possibility of concurrent oncological treatment and the patient’s current immune status.
The authors will present the cases of four proctological patients with immune defects, which will provide a broader discussion of the treatment of this specific group of patients.
Introduction
Patients with compromised immunity constitute a growing group in society. These include those diagnosed with cancer, primarily those undergoing chemotherapy, patients receiving biological therapy for inflammatory bowel disease, or those receiving long-term immunosuppressive medications after organ transplantation, as well as individuals with acquired immunodeficiency syndrome due to HIV infection.
As many as 30% of cancer patients are affected by proctological disease, including 5-9% with hematological malignancies (1). Proctological symptoms may be directly related to the location of the cancer (e.g., an infiltrating tumor of the anal canal or rectum), but more often, proctological disease is the result of a weakened immune system in the patient following cancer treatment (anal abscess and/or fistula).
Indications for surgical treatment are limited in these cases due to reduced immunity (neutropenia) and impaired coagulation function (often including platelet dysfunction) (2).
When choosing a treatment method for these patients, several important aspects should be considered, including the patient’s current immune status and the possibility of concurrent oncological treatment (2). In these patients, an active inflammatory process is associated with the risk of fulminant infection, abscess formation, and septic shock. Active infection is a contraindication to radiotherapy, chemotherapy, bone marrow transplantation, other organ transplantation, immunosuppressive therapy, or biological therapy.
Four cases of immunocompromised patients with concomitant proctological disease are presented below, which will serve as a basis for discussing therapeutic approaches.
Case 1
A 48-year-old patient with chronic obstructive pulmonary disease (COPD) was admitted to our clinic in May 2025 with advanced squamous cell carcinoma of the anus infiltrating the rectum, inflammatory infiltration of the anorectal region, and pain syndrome secondary to the infiltrating tumor. According to his medical history, he had been treated at other facilities since 2023. In 2023, he presented to a proctologist with a fistula-like lesion in the anus with mucous discharge. At that time, computed tomography (CT) scans had already revealed a tumor in the rectosigmoid region, significantly narrowing the lumen of the gastrointestinal tract.
In the following months, the lesion began to take on the appearance of a fist-sized ulcer, with inflammatory infiltration, skin fistulas, and abundant purulent drainage. Over a five-month period, three excisions and drainage procedures were performed.
During the intervention, biopsies were collected for histopathological examination, the results of which were not available from the patient’s medical history.
In March 2025, the patient returned to the doctor with bleeding from the lesions and the anal canal. Another wound revision was performed, and the necrotic lesions were excised. The histopathological examination revealed squamous cell carcinoma.
One month later, due to increasing obstruction, a double-barrel colostomy was created laparoscopically in the descending colon.
The patient was scheduled for induction chemotherapy, which he skipped several cycles due to high inflammatory parameters. Imaging studies revealed a fluid collection within the mesorectum measuring 3 × 6 × 6 cm, suspected of being an abscess.
Ultimately, the patient was disqualified from receiving another dose of cytostatic medication and referred to the Emergency Room. He first visited our Center in May 2025.
Laboratory test results revealed elevated inflammatory parameters: CRP > 200 mg/L, leukocytosis around 20,000 – interestingly, with persistently negative procalcitonin.
Imaging studies revealed metastatic lesions within the pubic bone, infiltration of the urinary bladder, and a focal lesion in the liver.
After discussion at a radiology consultation, the collection within the mesorectum was determined to be an extensive infiltrate with neoplastic lysis and signs of necrosis, therefore drainage was not considered (fig. 1). Drainage was performed in the perianal area, within the extensive tumor infiltration with inflammatory infiltration. The tumor was unresectable.
Fig. 1. Neoplastic lesion with signs of necrosis and lysis
Endoscopy, which was only possible in the operating room after the patient was anesthetized, revealed disintegrating tumor tissue within the rectum, without signs of an abscess. Drainage was performed between the incisions to allow drainage of the inflammatory material (fig. 2).
Fig. 2. Advanced squamous cell carcinoma of the anus. Extensive tumor infiltration with inflammatory infiltration. Status after Hippocratic drainage. Unresectable lesion
Additionally, antibiotic therapy with ceftriaxone and metronidazole was initiated, ultimately consistent with the results of the cultures collected from the cutaneous fistulas.
The patient returned to our Center in August 2025, disqualified from further chemotherapy.
Further surgical interventions were waived. Antibiotic therapy with meropenem was initiated based on the results of the subsequent culture, but without satisfactory results and decreased inflammatory parameters. After an oncology consultation and consultation with a radiotherapist due to severe pain associated with tumor infiltration, the patient was qualified for palliative radiotherapy to reduce the tumor mass.
Case 2
A 56-year-old patient, treated for ovarian cancer, presented to the Clinic with an anal fistula. The patient’s medical history included a hysterectomy performed 8 months earlier and chemotherapy completed 7 days before admission to our Department. A transrectal ultrasound performed 4 months earlier showed a high, bilaterally blind transsphincteric fistula with a branch to the Bartholin gland.
A few weeks before admission, spontaneous perforation of the fistula occurred, and preoperative examination revealed a complete tract.
The patient was scheduled for expedited surgery, and drainage of the fistula tract with a loose seton was performed in the operating room (fig. 3).
Fig. 3. Hippocratic drainage of the fistula connecting the anal canal with the vaginal vestibule
The patient was discharged from the hospital the following day. She returned four days later with a fever of 38.5°C and severe pain. Physical examination and ultrasound revealed no evidence of an abscess.
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Piśmiennictwo
1. Ashkar C, Britto M, Carne P et al.: Perianal sepsis in neutropaenic patients with haematological malignancies: the role of magnetic resonance imaging and surgery. ANZ J Surg 2020; 90(9): 1642-1646.
2. Kołodziejczak M, Ciesielski P: Choroby proktologiczne. Diagnostyka i leczenie. Wydawnictwo Lekarskie PZWL, Warszawa 2022.
3. Szawłowski AW: Powikłania chirurgiczne po chemioterapii i radioterapii. [W:] Jeziorski A, Szawłowski AW, Towpik E (red.): Chirurgia onkologiczna. Tom 2. Wydawnictwo Lekarskie PZWL, Warszawa 2009: 473-484.
4. Szawłowski AW, Wallner G: Stany nagłe w onkologii. Występowanie i leczenie. Tom 2. Wyd. I. Termedia, Poznań 2015.
5. Baker B, Al-Salman M, Daoud F: Management of acute perianal sepsis in neutropenic patients with hematological malignancy. Tech Coloproctol 2014; 18(4): 327-333.
6. Munoz-Villasmil J, Sands L, Hellinger M: Management of perianal sepsis in immunosuppressed patients. Am Surg 2001; 67: 484-486.
