Perineal skin recurrence on the site of Lone Star Retractor: case report
© The Author(s). 2017
Received: 25 August 2017
Accepted: 3 December 2017
Published: 28 December 2017
Local recurrence of colorectal cancer is a major cause of morbidity and mortality that usually implies a worse prognosis. Its etiopathogenesis is still a subject of debate. Recurrence on the perineal wound caused by anal retractor device is rarely reported.
We present the case of a 75-year-old woman with perineal skin recurrence on the site of Lone Star Retractor™ from rectal adenocarcinoma. The patient underwent a curative proctectomy followed by a hand-sewn coloanal anastomosis using Lone Star Retractor™ 2 years ago for a tumor of the lower rectum. The recurrence was most likely caused by the seeding of exfoliated tumor cells into the perianal skin which was abraded by the retractor.
This case is the fourth case reported in the literature and highlights the importance of the use of less traumatic endoanal retractors to prevent such perianal recurrence. Recurrence on the perineal wound caused by anal retractor device is rare but possible. Further studies are needed to define preventive measures able to reduce cutaneous implants.
Local recurrence (LR) of colorectal cancer is a major cause of morbidity and mortality that usually implies a worse prognosis. The etiopathogenesis of LR is still a subject of debate, and this has led to major improvements in colorectal management [1–3]. After a curative resection of rectal cancer, LR is often the consequence of inadequate clearance of the tumor or the surrounding tissues; however, another mechanism to explain recurrence on preexisting benign perineal lesions is suggested by Guiss in 1954  who reported the first a case of implantation of cancer cells within a fistula-in-ano. Since this case, several case reports and small case series reported CCR recurrences on preexisting benign perineal lesions such as hemorrhoids [5–8], fistula [9–12], or on the anal wound caused by stapling device [13–15].
LR on the perineal wound caused by anal retractor device is rarely reported, with only three cases reported so far, one case on the scar of a Gelpi Retractor  and two on the site of Lone Star Retractor™ .
Herein, we report the fourth case of cutaneous perineal recurrence on the site of a Lone Star Retractor ™ system after a curative proctectomy and hand-sewn coloanal anastomosis for rectal cancer.
Local recurrence is a major cause of morbidity and mortality, usually implies a worse prognosis. It may occur as a result from two potential etiopathogeneses. First, metastases through endothelial-lined channels occur to both lymphatic and hematogenous routes , which are controlled by neoadjuvant therapy and optimal TME. Indeed, TME reduced the high local recurrence rates from 30–40% to 5–10%  and even greater when associated with chemoradiotherapy (CRT) . The second is by implantation of viable exfoliated malignant cells from a rectal adenocarcinoma on preexisting benign perineal lesions [21–24]; it was estimated that 70% of the specimens were found to have viable exfoliated colorectal cancer cells with median cell number ranging from 0.55 × 105 to 0.78 × 10 .
Since the first case of cell implantation into the anal fistula in 1954 by Guiss , several case reports and small case series reported the colorectal cancer recurrence on preexisting benign perineal lesions such as hemorrhoid [5–8], fistula [9–12], or on the anal wound caused by stapling device manipulation [2, 13–15]. In this case, the surgery was considered to be “curative” R0 resection; the mesorectum was complete, and the pathologic finding was tumor-free with adequate margins, but malignant cells had probably implanted into the perianal skin wound caused by the Lone Star Retractor hooks. Tranchart  and Cantos-Pallares  have reported three recurrence cases after using the same retractor. Zinzindohoue  reported a case of tumor recurrence on the scar of a Gelpi Retractor.
We propose, as Tranchart  did, the use of less traumatic endoanal retractors to prevent such perianal recurrence. Using intraoperative rectal washout with cytocidal solutions is usually recommended to reduce the amount and viability of malignant cells, a procedure that reduces the LR risk after anterior resection. Several studies have highlighted on the impact of washout on the LR rate after anterior resection with conflicting results . However, in both patients of Tranchart , and in this case, recurrence occurred despite preoperative rectal washing.
The management of colorectal cancer LR is still a matter of debate, it ranges from local excision [15–17] to a more aggressive approach [25, 27]. A local excision in case of cutaneous perianal metastases seems to be adapted because implantation of exfoliated tumor cells is distal to the anastomosis and not associated to pelvic recurrence . The previously reported LR on the site of retractor [16, 17, 25] was locally excised with wide margins, and no further adjuvant treatment was given. These patients did not show any other signs of recurrence a year later.
Local recurrence of colorectal cancer is a major cause of morbidity and mortality that usually implies a worse prognosis. Recurrence on the perineal wound caused by anal retractor device is rare but possible. The knowledge of this mechanism of occurrence may change surgical practices and push for further studies to define preventive measures that can reduce skin implants.
MH drafted the manuscript. AM participated in the correction of the manuscript. AH participated in the revising and drafting of the manuscript. MA participated in the revising of the manuscript. All authors read and approved the final manuscript.
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- MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet. 1993;341(8843):457–60. doi: 10.1016/0140-6736(93)90207-w.View ArticlePubMedGoogle Scholar
- Matsuda A, Kishi T, Musso G, Matsutani T, Yokoi K, Wang P, et al. The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis. Ann Surg Oncol. 2013;20(3):856–63. doi: 10.1245/s10434-012-2660-4.View ArticlePubMedGoogle Scholar
- Fan WH, Xiao J, An X, Jiang W, Li LR, Gao YH, et al. Patterns of recurrence in patients achieving pathologic complete response after neoadjuvant chemoradiotherapy for rectal cancer. J Cancer Res Clin Oncol. 2017;143(8):1461–7. doi: 10.1007/s00432-017-2383-9.View ArticlePubMedPubMed CentralGoogle Scholar
- Guiss RL. The implantation of cancer cells within a fistula in ano: case report. Surgery. 1954;36(1):136–9.PubMedGoogle Scholar
- Nash GF, Reddy KM, Booth RA. Perianal recurrence in colonic cancer. J R Soc Med. 1999;92(9):469.View ArticlePubMedPubMed CentralGoogle Scholar
- Hsu TC, Lu IL. Implantation of adenocarcinoma on hemorrhoidectomy wound. Int J Color Dis. 2007;22(11):1407–8. doi: 10.1007/s00384-006-0179-5.View ArticleGoogle Scholar
- Gujral DM, Bhattacharyya S, Hargreaves P, Middleton GW. Metastatic rectal adenocarcinoma within haemorrhoids: a case report. J Med Case Rep. 2008;2:128. doi: 10.1186/1752-1947-2-128.View ArticlePubMedPubMed CentralGoogle Scholar
- Liasis L, Papaconstantinou HT. Colorectal cancer implant in an external hemorrhoidal skin tag. Proc (Bayl Univ Med Cent). 2016;29(2):194–5.View ArticleGoogle Scholar
- Hyman N, Kida M. Adenocarcinoma of the sigmoid colon seeding a chronic anal fistula: report of a case. Dis Colon Rectum. 2003;46(6):835–6. doi: 10.1097/01.DCR.0000070041.09875.7C. View ArticlePubMedGoogle Scholar
- Shinohara T, Hara H, Kato Y, Asano M, Nakazawa Y, Kato T, et al. Implantation of rectal cancer cells in a fistula in ano: report of a case. Surg Today. 2001;31(12):1094–6. doi: 10.1007/s595-001-8065-9. View ArticlePubMedGoogle Scholar
- Hamada M, Ozaki K, Iwata J, Nishioka Y, Horimi T. A case of rectosigmoid cancer metastasizing to a fistula in ano. Jpn J Clin Oncol. 2005;35(11):676–9. doi: 10.1093/jjco/hyi181.View ArticlePubMedGoogle Scholar
- Gomes RM, Kumar RK, Desouza A, Saklani A. Implantation metastasis from adenocarcinoma of the sigmoid colon into a perianal fistula: a case report. Ann Gastroenterol. 2014;27(3):276–9.PubMedPubMed CentralGoogle Scholar
- Reed MW, Stoddard CJ. Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device. Ann R Coll Surg Engl. 1992;74(4):301–2.PubMedPubMed CentralGoogle Scholar
- Wind P, Douard R, Poupardin E, Cugnenc PH. Anal implantation of exfoliated tumour cells from a rectal adenocarcinoma after colorectal stapled anastomosis. Eur J Surg. 1999;165(9):905–6. doi: 10.1080/11024159950189447.View ArticlePubMedGoogle Scholar
- De Friend DJ, Kramer E, Prescott R, Corson J, Gallagher P. Cutaneous perianal recurrence of cancer after anterior resection using the EEA stapling device. Ann R Coll Surg Engl. 1992;74(2):142–3.PubMedPubMed CentralGoogle Scholar
- Zinzindohoue F, Penna C, Parc R. Adenocarcinoma arising on the site of a Gelpi Retractor after coloanal anastomosis for rectal cancer. Br J Surg. 1997;84(3):362. doi: 10.1046/j.1365-2168.1997.02544.x.View ArticlePubMedGoogle Scholar
- Tranchart H, Benoist S, Penna C, Julie C, Rougier P, Nordlinger B. Cutaneous perianal recurrence on the site of Lone Star Retractor after J-pouch coloanal anastomosis for rectal cancer: report of two cases. Dis Colon Rectum. 2008;51(12):1850–2. doi: 10.1007/s10350-008-9338-9.View ArticlePubMedGoogle Scholar
- Sugarbaker PH. Mechanisms of relapse for colorectal cancer: implications for intraperitoneal chemotherapy. J Surg Oncol Suppl. 1991;2(S2):36–41. doi: 10.1002/jso.2930480510.View ArticlePubMedGoogle Scholar
- Maslekar S, Sharma A, Macdonald A, Gunn J, Monson JR, Hartley JE. Mesorectal grades predict recurrences after curative resection for rectal cancer. Dis Colon Rectum. 2007;50(2):168–75. doi: 10.1007/s10350-006-0756-2.View ArticlePubMedGoogle Scholar
- Enriquez-Navascues JM, Borda N, Lizerazu A, Placer C, Elosegui JL, Ciria JP, et al. Patterns of local recurrence in rectal cancer after a multidisciplinary approach. World J Gastroenterol. 2011;17(13):1674–84. doi: 10.3748/wjg.v17.i13.1674.View ArticlePubMedPubMed CentralGoogle Scholar
- Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and in vitro growth in colorectal cancer. Br J Surg. 1987;74(11):1049–52.View ArticlePubMedGoogle Scholar
- McGregor JR, Galloway DJ, McCulloch P, George WD. Anastomotic suture materials and implantation metastasis: an experimental study. Br J Surg. 1989;76(4):331–4.View ArticlePubMedGoogle Scholar
- Tsunoda A, Shibusawa M, Tsunoda Y, Choh H, Takata M, Kusano M. Implantation on the suture material and efficacy of povidone-iodine solution. Eur Surg Res. 1997;29(6):473–80. doi: 10.1159/000129559.View ArticlePubMedGoogle Scholar
- Zhou C, Ren Y, Li J, Li X, He J, Liu P. Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer. J Surg Res. 2014;189(1):7–16. doi: 10.1016/j.jss.2014.01.030.View ArticlePubMedGoogle Scholar
- Cantos-Pallares M, Garcia-Armengol J, Mulas-Fernandez C, Sancho-Moya C, Fabra-Cabrera I, Bruna-Esteban M, et al. Perianal cutaneous metastases from colorectal adenocarcinoma. Rev Esp Enferm Dig. 2012;104(1):41–2.View ArticlePubMedGoogle Scholar
- Jorgren F, Johansson R, Arnadottir H, Lindmark G. The importance of rectal washout for the oncological outcome after Hartmann’s procedure for rectal cancer: analysis of population-based data from the Swedish Colorectal Cancer Registry. Tech Coloproctol. 2017;21(5):373–81. doi: 10.1007/s10151-017-1637-5.View ArticlePubMedPubMed CentralGoogle Scholar
- Kouraklis G, Glinavou A, Kouvaraki M, Raftopoulos J, Karatzas G. Anal lesion resulting from implantation of viable tumour cells in a pre-existing anal fistula. A case report. Acta Chir Belg. 2002;102(3):212–3. doi: 10.1080/00015458.2002.11679299.