Drain-site recurrence of an ileocaecal valve adenocarcinoma

Abstract

Drain-site recurrence following colorectal cancer resection is a rare event and is described in few case reports. The majority of these reports are following minimally invasive surgery. This report describes a case of an isolated drain-site recurrence of primary colorectal cancer in a male patient in his 50s. He previously underwent an open right hemicolectomy and segmental small bowel resection for an obstructing ileocaecal valve adenocarcinoma. This was followed by adjuvant chemotherapy. Two years into surveillance, a redo ileocolic resection was performed for an anastomotic recurrence. While undergoing surveillance imaging, a new deposit was detected at a right-sided surgical drain site. Subsequently, a full thickness en bloc resection was performed. To date, the postoperative course has been uneventful. This case describes a drain-site recurrence from a colorectal primary.

Background

Wound recurrence in cancer surgery is defined as local, circumscribed tumour growth at the site of one or more trocar sites or at an incision site after laparoscopic, thoracoscopic or open surgery for cancer, though a rare occurrence has been found to be associated with a variety of primaries, namely, gastric, bladder, cervical, endometrial, ovarian, prostate, hepatocellular and neuroblastoma.¹

It has a significant association with morbidity and mortality, thus highlighting the importance of adherence to surveillance regimes and multidisciplinary team (MDT) discussion for atypical findings. This case reports the rare presentation of a second tumour recurrence at a drain site. Following initial right hemicolectomy and adjuvant chemotherapy, a surveillance colonoscopy revealed a small mass at the anastomosis. This was treated with a redo ileocolic resection.

Case presentation

Four years prior to the current report of a male patient in his 50s, the patient presented to the emergency department with central abdominal pain, nausea, vomiting, constipation, unremarkable blood profiles and a distended abdomen on examination. A CT scan of the abdomen and pelvis led to a diagnosis of small bowel obstruction and subsequent colonoscopy revealed a moderately differentiated adenocarcinoma at the ileocaecal valve as the underlying cause. An open right hemicolectomy with segmental small bowel resection was performed due to an obstructing ileocaecal valve tumour involving the terminal ileum, invading the caecum. The final pathology was a pT4aN1b, R0 resection. Following MDT discussion, 12 cycles of adjuvant FOLFOX were administered. Two years into surveillance, anastomotic-site recurrence was detected on colonoscopy. Following a positron emission tomography (PET)–CT scan to out rule disseminated disease, the recurrence was managed by a redo open ileocolic resection.

Investigations

Imaging

At 1 year post the redo ileocolic resection, surveillance CT scan of the thorax, abdomen and pelvis demonstrated a 1 cm deposit at the site of the right abdominal drain inserted post right hemicolectomy (figure 1).

Figure 1.

Axial slice of a CT scan of the thorax, abdomen and pelvis, showing a right abdominal wall soft tissue deposit suspicious for drain-site metastasis (blue arrow).

Following MDT discussion, an ultrasound-guided biopsy was performed, and histology revealed adenocarcinoma consistent with a colorectal primary tumour. Repeat MDT discussion advised a PET–CT scan, which did not demonstrate other sites of tumour recurrence or metastasis (figure 2).

Figure 2.

Image from positron emission tomography (PET) scan showing the abdomen and pelvis highlighting a right abdominal wall soft tissue deposit suspicious for drain-site metastasis (blue arrow).

Differential diagnosis

Not applicable.

Treatment

A full thickness en bloc excision of the abdominal wall mass was advised by the MDT. Preoperative marking of the abdominal wall mass was performed (figures 3 and 4). This excision included skin, fat, muscle and peritoneum allowing for additional extended margins to be excised (figure 5). Abdominal wall reconstruction was then performed by interrupted sutures (figure 6) and the use of a on lay mesh. A 10×15 cm DynaMesh CICAT mesh was tacked to the external aponeurosis by tacks (figure 7). A negative pressure wound dressing (Prevena) along with a suction drain were sited (figure 8), and an abdominal binder was placed postoperatively.

Figure 3.

Image from ultrasound study depicting the right abdominal wall lesion suspicious for drain-site metastasis (blue arrow) and its dimensions (white crosses).

Figure 4.

Clinical photograph of the abdomen with the site of the soft tissue lesion marked using ultrasound guidance prior to surgery. Blue arrow highlights the lesion marked for excision.

Figure 5.

Intraoperative clinical photograph depicting the defect created by full thickness excision of the drain-site metastasis.

Figure 6.

Intraoperative clinical photograph depicting the repair of the post excision abdominal wall defect by interrupted 1-0 PDS sutures.

Figure 7.

Intraoperative clinical photograph depicting the application of an on lay mesh post full thickness excision of the port-site metastasis.

Figure 8.

Clinical photograph depicting the application of a Prevena dressing at the site of the surgical incision after closure to promote healing.

Outcome and follow-up

The patient has been well postoperatively. He was at his baseline and discharged from physiotherapy on day 1 post operation, tolerating a high-calorie diet with additional supplements, to promote wound healing by day 2. The redivac drain was removed on day 5 and he was discharged from an inpatient setting. On day 7, he was reviewed in the dressing clinic, and the negative pressure wound therapy device (Prevena) was removed and his surgical scars were inspected. The surgical skin clips were then removed by the general practitioner at day 10. He returned for a surgical outpatients’ appointment at the 2-week postoperative milestone with ongoing follow-up every 3–6 months. Thus far, there has been no suspicious history or clinical examination to suggest recurrence, metastasis, abdominal wall weakness or hernia development.

Histology

A full thickness abdominal wall en bloc resection with additional margins was sent as two separate samples for histological analysis. The macroscopic findings (figure 9) included a white semi-firm nodule at 60 mm deep to the skin and measured 20 mm in maximum dimension. It was 2 mm from the circumferential margin and 15 mm from the deep margin. Microscopically (figure 10), a subcutaneous deposit of metastatic adenocarcinoma, colorectal type with abundant necrosis and multiple foci of lymphovascular space invasion were seen with the additional margins free of malignancy. There was no local lymphadenopathy.

Figure 9.

Photograph of specimen delivered by en bloc excision of abdominal wall lesion to be sent for histological analysis.

Figure 10.

Transverse section of a microscopic view of resected port-site metastasis depicting subcutaneous deposit of metastatic adenocarcinoma, colorectal type, with abundant necrosis and multiple foci of lymphovascular space invasion.

Discussion

Regardless of the primary carcinoma, metastasis solely at the surgical drain site seems to be a rare event. Only limited numbers of case reports describe metastasis at the surgical drain site in patients with pancreatic, cervical, colorectal, thyroid, oesophageal and breast cancer.² Clinical studies have shown that the incidence of abdominal wall recurrence is approximately 1% after laparotomy for colorectal cancer.³ This case reports the rare presentation of port-site recurrence post resection and adjuvant chemotherapy for a primary colorectal tumour at the ileocaecal valve.

In both open and laparoscopic surgery, the biological basis of the wound recurrence seems to be identical.¹ While the cause of wound site recurrence is still not clear, it has been postulated that it is multifactorial in origin and likely related to factors such as patient-related, tumour-related, wound-related and surgical technique-related factors.^{4 5}

A tumour of the ileocaecal valve, as our case presents, is a rare occurrence with few reported cases,⁶ with the majority demonstrating adenocarcinoma on histology.⁷ While right-sided tumours are known to be generally of higher stage than left-sided tumours, one study of 1003 ileal and colorectal tumours found 19.8% to be ileocaecal junction carcinomas, which were found to be higher staged tumours than other right-sided cancers and those involving the ileocaecal valve directly showed significantly decreased survival.⁷

Yoruk et al presented a patient with right hypochondrial pain and a vague lump, 1 year after resection of an ileal adenocarcinoma with adjuvant chemotherapy. Fine needle aspiration cytology of the lesion was inconclusive and warranted a staging laparoscopy. Once an isolated lesion was confirmed wide local excision of the lesion was performed.⁶

Another case report described recurrence at the surgical drain site of an ascending colonic tumour which presented with acute perforation and was managed with an emergency right hemicolectomy. The final histology was a stage III mucinous adenocarcinoma, and represented with liver metastasis 9 months postoperatively, and an additional drain-site recurrence at 17 months following initial presentation.⁸

In general, patients with wound recurrences have had more advanced disease at the time of surgery and most wound recurrences have been associated with metastases in other organs.⁸

While our case does not involve metastasis in another organ, it does involve two episodes of recurrence of the same advanced-stage tumour, that is, at the initial ileocolic anastomosis and the drain site. In addition to advanced stage, it is important to note that clinical presentation with obstruction, bowel perforation and emergent surgery have been identified as independent risk factors for locoregional recurrence.⁹

In a case of sigmoid adenocarcinoma, drain-site recurrence is reported 1 year post left hemicolectomy.¹⁰ The initial presentation was that of an ulcerated lesion at the drain site which was diagnosed as chronic wound infection but was later found to be associated with malignant cells and developed into a large fungating mass. A population-based study of 1856 patients found tumours of the right colonic flexure and sigmoid colon to be associated with a significantly increased risk of locoregional recurrence.⁹

When investigating an asymptomatic abdominal wall lesion, biopsy and histological assessment is required to differentiate between pathologies. This can help differentiate between other benign presentations such as hyperplastic granulation tissue, keloid scars and desmoid tumours.³ Hughes et al conducted a case series whereby 11 of 1603 patients developed recurrence at their abdominal incision after curative resection of large bowel cancer.¹¹ The outcome of this series was extremely poor as all were deceased within 4 years and highlights the importance of investigating new abdominal wall lumps identified on surveillance clinical examinations.

Yan and Sugarbaker noted that for mucinous adenocarcinoma and peritoneal mesothelioma, total resection of the rectus abdominis muscle resulted in excellent disease control within the abdominal wall.¹² While mesh was not used in these cases and there were no reports of abdominal wall recurrence, it should be noted that direct oncologic resection of the abdominal wall is associated with postoperative flank weakness and/or hernia at a reported rate ranging from 8% to 57%, hence we used the mesh repair technique in our case.¹³

Learning points.

• Port-site metastases are associated with significant morbidity and mortality which justifies the need for vigilant surveillance.

• Skin examination should be part of follow-up review clinics even after a long asymptomatic period, all skin nodules, non-healing ulcers and persistent indurate erythema allowing early diagnosis and appropriate management.

• Patients should be educated on scar and skin inspection postoperatively and report any evolution or new lesions to their primary physician.

• Patients with risk factors for locoregional recurrence, such as right-sided colonic tumours, emergency presentation with perforation or obstruction or mucinous histology, should be flagged for closer wound surveillance.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).