Adenocarcinoma of transposed colon: first case of synchronous tumor

INTRODUCTION

The surgical and anatomical basis for using the colon as a substitute for the esophagus were established in 1911 by Kelling and Vuillet11. Liau CT, Hsueh S, Yeow KM. Primary adenocarcinoma arising in esophageal colon interposition: report of a case. Hepatogastroenterology 2004; 51(57): 748-9. and for many years was the technique of choice for esophageal replacement22. Klink CD, Binnebösel M, Schneider M, Ophoff K, Schumpelick V, Jansen M. Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience. Surgery 2010; 147(4): 491-6.. Its use is helpful in benign diseases, such as caustic or peptic strictures, and malignancies11. Liau CT, Hsueh S, Yeow KM. Primary adenocarcinoma arising in esophageal colon interposition: report of a case. Hepatogastroenterology 2004; 51(57): 748-9. , 33. Licata AA, Fecanin P, Glowitz R. Metastatic adenocarcinoma from oesophageal colonic interposition. Lancet 1978; 311(8058): 285., especially when the stomach cannot be used, and also in children with congenital anomalies22. Klink CD, Binnebösel M, Schneider M, Ophoff K, Schumpelick V, Jansen M. Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience. Surgery 2010; 147(4): 491-6. , 44. Altorjay A, Kiss J, Vörös A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995; 42(6): 797-9.. However, this procedure is subject to early complications, as ischemia of the colon and leakage55. Houghton AD, Jourdan M, McColl I. Dukes A carcinoma after colonic interposition for oesophageal stricture. Gut 1989; 30(6): 880-1., or late problems as anastomosis stenosis, ischemic colitis, fistula due to diverticulitis and malignant lesions44. Altorjay A, Kiss J, Vörös A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995; 42(6): 797-9..

The transposed colon cancer is a rare complication. Since 2007, six new cases were reported and two reviews published. Hwang et al66. Hwang HJ, Song KH, Youn YH, Kwon JE, Kim H, Chung JB et al. A case of more abundant and dysplastic adenomas in the interposed colon than in the native colon. Yonsei Med J 2007; 48(6): 1075-8. found 10 reported cases of adenocarcinoma in the transposed colon and Bando et al77. Bando H, Ikematsu H, Fu KI, Oono Y, Kojima T, Minashi K et al. A laterally-spreading tumor in a colonic interposition treated by endoscopic submucosal dissection. World J Gastroenterol 2010; 16(3): 392-4. also reviewed 10 cases in the literature, encompassing adenomas and adenocarcinomas.

The aim is to report an unique case of synchronous adenocarcinoma of the transposed colon.

CASE REPORT

Woman with 53-years-old diagnosed with congenital esophageal atresia, underwent to several surgical procedures in childhood, the latest was a cervical retrosternal esophagocoloplasty at 11 years old. After 42 years she was evolved with cervical dysphagia, and an initial diagnosis of stenosis of the esophagocolic anastomosis was performed, treated with endoscopic dilation without improvement. Later, biopsies were performed in the area of ​​stenosis in proximal colonic segment (Figure 1) and polypectomy of sessile polyp of 10 mm, 5 cm distal to the stenosis (Figure 2). The pathological assessment showed tubular-villous intramucosal adenocarcinoma at the resected polyp and the area of ​​stenosis was a invasive adenocarcinoma in colonic mucosa. Colonoscopy of remained colon was normal. Staging performed with CT scan showed an eccentric wall thickening of proximal colon transposed with luminal reduction target of left innominate vein; densification of mediastinal fat plane adjacent and regional lymph nodes up to 1.9 cm.

Figure 1
Endoscopic view of the stenotic area in proximal colonic segment with advanced adenocarcinoma

Figure 2
Endoscopic view of the sessile polyp with sincronous intramucosal adenocarcinoma at the transposed colon more distal

Surgical treatment was performed with neck incision, sternotomy and laparotomy with resection of the colon transposed and a tactic transhiatal esophagectomy of the atresic esophagus in order to pull up the greater curvature gastric conduit obtained by the posterior mediastinum route. Resection of a portion of the left innominate vein which was invaded by the tumor was also performed. The pathological examination of surgical specimen showed moderately differentiated tubular adenocarcinoma invading pericolical tissues and the left innominate vein, with no affected lymph nodes - p T4 N0 (0 / 42) M0.

The patient developed postoperative superior vena cava syndrome, treated by anticoagulation. She had ischemia of the proximal portion of the stomach transposed being performed partial gastrectomy, and respiratory complications. She remained in intensive care and under multidisciplinary clinical support. Discharge of the hospital was after 128 days. Patient developed recurrent disease (lung metastases), started chemotherapy, and died nine months after surgery due to pneumonia.

DISCUSSION

There are basically three options for replacement after esophageal resection: stomach, colon and small bowel88. Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg 2003; 138(3): 303-8.. For many years, the colon was considered the organ of choice, but the stomach has been the most widely used in recent decades due facility of preparation of the gastric conduit and its more robust vascular supply as a result of a rich submucosal vascular layer99. Mine S, Udagawa H, Tsutsumi K, Kinoshita Y, Ueno M, Ehara K et al. Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer. Ann Thorac Surg 2009; 88(5): 1647-53.. Resection of the gastric lesser curvature allows elongation and a safe cervical anastomosis88. Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg 2003; 138(3): 303-8. , 1010. Rizzetto C, DeMeester SR, Hagen JA, Peyre CG, Lipham JC, DeMeester TR. En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2008; 135(6): 1228-36. , 1111. Young MM, Deschamps C, Trastek VF, Allen MS, Miller DL, Schleck CD et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000; 70(5): 1651-5..

In cases of previous gastrectomy, gastric caustic or peptic strictures, tumor involvement of the stomach or failed gastroplasty the colon is used99. Mine S, Udagawa H, Tsutsumi K, Kinoshita Y, Ueno M, Ehara K et al. Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer. Ann Thorac Surg 2009; 88(5): 1647-53.. Colonic interposition may have early complications as transposed colon ischemia and anastomotic fistula. Late complications as anastomotic stricture "redundant graft", ulceration, colitis, perforation, diverticulitis, or tumor in the colonic segment are reported44. Altorjay A, Kiss J, Vörös A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995; 42(6): 797-9. , 55. Houghton AD, Jourdan M, McColl I. Dukes A carcinoma after colonic interposition for oesophageal stricture. Gut 1989; 30(6): 880-1.. Must be remembered that colorectal cancer has a high incidence; is the third leading cause of cancer diagnosed in men and second among women in the world1212. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011; 61: 69-90. and this colonic segment has a risk for malignancy too. There are 21 cases of adenoma/adenocarcinoma in transposed colon described in literature11. Liau CT, Hsueh S, Yeow KM. Primary adenocarcinoma arising in esophageal colon interposition: report of a case. Hepatogastroenterology 2004; 51(57): 748-9. , 33. Licata AA, Fecanin P, Glowitz R. Metastatic adenocarcinoma from oesophageal colonic interposition. Lancet 1978; 311(8058): 285.

4. Altorjay A, Kiss J, Vörös A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995; 42(6): 797-9.

5. Houghton AD, Jourdan M, McColl I. Dukes A carcinoma after colonic interposition for oesophageal stricture. Gut 1989; 30(6): 880-1.

6. Hwang HJ, Song KH, Youn YH, Kwon JE, Kim H, Chung JB et al. A case of more abundant and dysplastic adenomas in the interposed colon than in the native colon. Yonsei Med J 2007; 48(6): 1075-8.
- 77. Bando H, Ikematsu H, Fu KI, Oono Y, Kojima T, Minashi K et al. A laterally-spreading tumor in a colonic interposition treated by endoscopic submucosal dissection. World J Gastroenterol 2010; 16(3): 392-4..

This case shows that all patient underwent to esophagocoloplasty and develops dysphagia during late follow-up should be investigated for malignancy and the initial diagnosis of stenosis of the esophagocolic anastomosis without biopsy should be evoid.

REFERENCES

  • 1
    Liau CT, Hsueh S, Yeow KM. Primary adenocarcinoma arising in esophageal colon interposition: report of a case. Hepatogastroenterology 2004; 51(57): 748-9.
  • 2
    Klink CD, Binnebösel M, Schneider M, Ophoff K, Schumpelick V, Jansen M. Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience. Surgery 2010; 147(4): 491-6.
  • 3
    Licata AA, Fecanin P, Glowitz R. Metastatic adenocarcinoma from oesophageal colonic interposition. Lancet 1978; 311(8058): 285.
  • 4
    Altorjay A, Kiss J, Vörös A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995; 42(6): 797-9.
  • 5
    Houghton AD, Jourdan M, McColl I. Dukes A carcinoma after colonic interposition for oesophageal stricture. Gut 1989; 30(6): 880-1.
  • 6
    Hwang HJ, Song KH, Youn YH, Kwon JE, Kim H, Chung JB et al. A case of more abundant and dysplastic adenomas in the interposed colon than in the native colon. Yonsei Med J 2007; 48(6): 1075-8.
  • 7
    Bando H, Ikematsu H, Fu KI, Oono Y, Kojima T, Minashi K et al. A laterally-spreading tumor in a colonic interposition treated by endoscopic submucosal dissection. World J Gastroenterol 2010; 16(3): 392-4.
  • 8
    Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer. Arch Surg 2003; 138(3): 303-8.
  • 9
    Mine S, Udagawa H, Tsutsumi K, Kinoshita Y, Ueno M, Ehara K et al. Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer. Ann Thorac Surg 2009; 88(5): 1647-53.
  • 10
    Rizzetto C, DeMeester SR, Hagen JA, Peyre CG, Lipham JC, DeMeester TR. En bloc esophagectomy reduces local recurrence and improves survival compared with transhiatal resection after neoadjuvant therapy for esophageal adenocarcinoma. J Thorac Cardiovasc Surg 2008; 135(6): 1228-36.
  • 11
    Young MM, Deschamps C, Trastek VF, Allen MS, Miller DL, Schleck CD et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000; 70(5): 1651-5.
  • 12
    Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011; 61: 69-90.
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Publication Dates

  • Publication in this collection
    Jul-Sep 2014

History

  • Received
    24 Jan 2013
  • Accepted
    18 Dec 2013
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