Rectal Cancer with Intramural Metastasis Manifesting as Vaginal Invasion: Report of a Surgical Resection

Satoshi Mizutani, Takeshi Shioya, Tetsuo Shibuya, Koshi Matsumoto^*, Hiroaki Fujii^** and Yukichi Moriyama

Gastrointestional Disease Center, Pathology^*, Nippon Medical School 2^nd
Hospital and Pathology, Juntendo University^**

We report a rare case of distal intramural metastasis by rectal cancer. A 63-year-old woman was admitted to a gynecological hospital for irregular genital bleeding. Ba-enema examination and colonoscopy disclosed cancer of the upper rectum. An elevated lesion (1.5 cm) at the posterior wall of the fornix vaginae was detectede by vaginoscopy and this was preoperatively diagnosed as multiple rectal cancer. Abdominal computed tomography (CT) and angiography suggested a metastatic liver tumor of left lobe (H1). Posterior pelvic exenteration, left lobectomy of the liver, and cholecystectomy were done. Macroscopically type 2 rectal cancer was found and a polipoid lesion separated 7cm from the main tumor was located in the anus. Histopathologically, the main tumor in the upper rectum (circled) was a moderatelly differentiated adenocarcinoma and a1 n1, while the anal polipoid lesion was intramural metastasis of the rectal cancer. The presence of the tumoral embolism in lymphatic vessels, the growth pattern mostly at the submucosal and muscle layers, and the similarity of structural and cellular heterogenisity showed the polipoid lesion to be intramural metastasis invading the vagina. Furthermore in the DNA analysis, loss of heterozygosity of these tumors was consistent with the histopathological finding. Intramural metastasis (spread) in rectal cancer is rare. This is, to our knowledge, the first report to demonstrate that intramural metastastic tumor is located about 7 cm from main tumor and it invades vagina. Rectal cancer with intramural metastasis has a poor prognosis. We should have meticulous care for follow up in this case.

Key words
rectal cancer, intramural metastasis

Reprint requests
Satoshi Mizutani Nippon Medical School 2^nd Hospital Gastro-intestional Disease Center 1-396 Kosugi Nakahara Kawasaki Kanagawa JAPAN

Accepted
March 26, 2003

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