Robotic surgery for rectosigmoid junction tumor with ovarian metastases.

Isolated ovarian metastases from colorectal cancer (CRC) are rare disease presenting in approximately 3% of all patients undergoing colorectal resection. Most reports describe an open approach to the disease, but we report a case isolated ovarian metastases from CRC managed completely by robotic technique. A 54-year-old female, with a family history of CRC, was admitted for rectosigmoid junction cancer. Computed tomography scan demonstrated in rectosigmoid tumor and pelvic mass, presumed as teratoma. Robotic surgery discovered a 10-cm encapsulated tumor, attached to the left ovary, with no macroscopic peritoneal involvement. The pathologic diagnosis of the resected pelvic mass, ovarian metastases from CRC. Robotic anterior resection was performed. Operative time was lasted 165 min, considering 25 min for robotic system set up. This is the first report to describe robot-assisted anterior resection and oophorectomy in patient with isolated ovarian metastases from rectosigmoid junction cancer.

INTRODUCTION

The incidence of metastatic ovarian tumors originating from primarily colorectal cancers (CRCs) is presented between 1% and 8% in clinical series.[123] About 95% of these metastatic tumors occur synchronous and frequently have settlement bilaterally.[4] Effect of prophylactic oophorectomy on survival, especially in postmenopausal women is minimal.[5] Robotic surgery is one of the most important developments for minimally invasive surgery. The first few cases of colonic surgery using da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) were reported in 2002.[67] In the years following, different centers have published their robotic experiences. In this article, resection of a pelvic mass using completely robotic technique is described in a patient with rectosigmoid tumor, which is interesting, preoperative pelvic mass described as a teratoma, although it was detected of isolated ovarian metastases from rectosigmoid junction cancer.

CASE REPORT

A 54-year-old female patient without any symptoms, admitted to our clinic because of history of CRC in her mother. There was no palpable mass on physical examination, no evidence of anemia and elevation of tumor markers in laboratory parameters. In colonoscopy, we have seen ulcerating tumor approximately 15th cm from the anal verge [Figure 1]. Multiple biopsies were taken and pathological examination revealed moderately differentiated adenocarcinoma. A computed tomography (CT) scan of the abdomen showed a huge mass (10 cm × 9 cm) in the pelvis and bowel wall thickening in left colon [Figure 2]. The wall of the cystic mass contained areas of calcification and there was a 9-mm area of calcification in the mass which is looking like an ossification area. There was no relationship to the adjacent tissues and the mass had regular margin. This pelvic mass was interpreted as a teratoma by CT scan. Gynecological evaluation with transvaginal ultrasonography showed the cystic mass did not originate from ovarium. We have made preoperative mechanical bowel cleansing and applied antibiotic prophylaxis by given 1 g cefazolin and 500 mg metronidazole intravenous. We used da Vinci® Surgical System for the robotic surgery. After induction, the patient was placed in a modified lithotomy position with the legs apart. A 12-mm trocar was placed through an incision 3-cm right and 2-cm above umbilicus after achievement of pneumoperitoneum. A 30° standard 12-mm robotic endoscope then was inserted through this trocar. The first 8-mm trocar was placed on the right spinoumbilical line at the crossing of mid-clavicular line. The second 8-mm trocar was inserted on the left spinoumbilical line at the crossing of mid-clavicular line. The third 8-mm trocar was inserted in the left upper quadrant. The 12-mm trocar was placed in the right upper quadrant for assistant port. During surgery, we deducted a rectosigmoid junction tumor, which does not exceed serosa of the bowel. In the exploration of the pelvic mass, we have seen the mass had regular margin, ıt was mobile and associated with only the left ovary [Figure 3]. The mass was resected with left ovary and salpinx and led out in endobag [Figure 4]. Robotic anterior resection was performed and colorectal anastomosis was performed as intracorporeal with 31-mm circular stapler [Figure 5]. There was no anastomotic leak was shown that with the air test. Intraoperative frozen section of the mass was defined as metastatic adenocarcinoma. Right salpingo-oophorectomy was performed for the possible bilateral ovarian involvement. Operation time was lasted 165 min, considering 25 min for robotic system set up. Postoperative 2nd day oral feeding was started. The postoperative 5th day the patient was discharged. Eighteen-reactive lymph nodes and one-metastatic lenf node found by as a result of pathological examination. Tumor diameter was 4-cm and there was no tumor proximal, distal, and circumferential radial margin. The tumor is advanced to subseroza layer, but had not infiltrated the serosa. The pelvic mass defined by pathology the isolated colorectal adenocarcinoma metastasis to the only left ovary.

Figure 1

Colonoscopic examination reveals an ulcerating tumor in the rectosigmoid junction

Figure 2

Computed tomography scan showing the large pelvic mass

Figure 3

Rectosigmoid junction tumor and pelvic mass

Figure 4

The pelvic mass was resected robotically and led out in endobag

Figure 5

Intracorporeal colorectal anastomosis with circular stapler

DISCUSSION

In this paper, we reported a patient who had robot-assisted resection for rectosigmoid junction cancer with left ovarian metastasis. Calcifications were seen in the preoperative CT scan and initially the mass supposed as teratoma. First, pelvic mass resection with left salpingo-oophorectomy was performed and en-bloc tissues were sampled for intraoperative frozen section. A diagnosis of adenocarcinoma was made by histology and surgical management completed with robot-assisted anterior resection and right salpingo-oophorectomy.

Colorectal cancer ovarian metastasis frequently occur bilaterally and dissemination mechanisms of the tumor include hematogenous, lymphatic and direct spreads.[89] Hematogenous spread is supported by bilateral ovarian involvement, lymphatic spread is supported by retrograde flow following the obstruction of lumbar lymphatic canals and peritoneal involvement of primary rectosigmoid or cecal tumors suggest direct dissemination. In this report, tumor was restricted in the subseroza, only one (epicolic region) of the 18 lymph node was positive and angiolymphatic invasion was present. In our patient, the tumor was present only in left ovary this makes us to think that the possible invasion occurred lymphatic pathway. Although it is not pathognomonic, negative cytokeratin (CK7) and positive CK20 at immunohistochemical staining strongly support ovarian metastasis of colorectal adenocancers.[10] In our case, CK20 and CDX2 was positive while CK was negative. Most of the ovarian metastasis of CRCs were synchronous, only 5% of the cases were encountered as metachronous in 2 years following tumor resection.[411] This common presentation of ovarian metastasis causes discussions concerning prophylactic bilaterally oophorectomy in postmenaposal women. A randomized prospective trial suggests that prophylactic bilaterally oophorectomy did not effect on the prognosis.[12] In our patient, in the preoperative period, we did not think that the pelvic mass was originated from ovarian metastasis. Calcifications in CT scan suggested that the mass was teratoma. On the occasion of this case, we want to remind that even with calcifications in the over CRC metastasis should be kept in the mind.

Management of CRC with minimally invasive surgery is commonly queried approach. Robotic surgery is a safe technique in treatment of CRC that compared favorably with laparoscopic surgery in short term outcomes.[1314] The advantage of robot colectomy was a lower blood loss compared with laparoscopic colectomy. However, the operative time was longer in robotic colectomy than that of laparoscopic colectomy. In this patient, we managed the surgery by robot-assisted approach. As we know this case is the first robotic anterior resection and bilateral salpingo-oophorectomy presentation in the literature. In this case, the preoperative diagnosis was teratoma. Nevertheless, we have recognized that the CRC was originated from isolated over metastasis, at least for this case, we would perform robotic surgery. All the surgical steps applied to the patient were appropriate to oncological surgery principles. The postoperative course was uncomplicated, the recovery was smooth and quick and chemotherapy cure was initiated without delay. During the 28 months follow-up period no recurrence was occurred.

As a result, this is the first patient undergoing robot-assisted surgery for the resection of rectosigmoid junction cancer with the isolated left ovarian metastasis. This manuscript is important because it demonstrates that ovarian metastasis of CRCs can be also managed completed with robotic surgery as primary CRCs.