A rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis: a case report and a review of the literature

We report herein, a patient with a rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis, and discuss a surgical policy for these lesions with reference to other such cases reported in the literature. A 40 year old female was admitted with a rectal mass and colonoscopy revealed a subpedunculated lesion, 1 cm in diameter, with a depression in its tip. A diagnosis of carcinoid was made by biopsy and transsacral excision performed. The excised specimen revealed a subpedunculated lesion measuring 7 X 6 X 6 mm with a central depression. The tumor was histologically confined to the submucosa but lymphatic invasion with pararectal lymph node involvement was observed. A radical proctectomy was thus performed. The incidence of metastasis from rectal carcinoids with a diameter of 1 cm or less is very low ranging from 1.5 to 3.4 per cent, and it therefore seems that most lesions of 1 cm or less in diameter can be treated by local excision alone. Thus, although it is recommended that local excision be performed first to determine the extent of spread, lymphatic vessel invasion and lymph node metastasis, radical surgery is indicated if lymphatic invasion or nodal involvement is present, even when muscle invasion is absent.     

Treatment of rectal carcinoid tumors

We investigated the treatment of 24 rectal carcinoid tumors from both the clinicopathologic and prognostic viewpoints. All tumors less than 2 cm in diameter had neither muscle layer invasion nor lymph node metastasis, except for an atypical carcinoid tumor that had both lymphatic permeation and intramural metastasis. One typical carcinoid tumor larger than 2 cm had both several lymphatic permeations and urinary bladder invasion. All cases had a good prognosis with no recurrence and no new metastases. For rectal carcinoid tumors less than 2 cm in diameter, local resection is sufficient, whereas radical operation is required for tumors larger than 2 cm in diameter. For atypical rectal carcinoid tumors, radical operation should be considered even if the diameter is less than 2 cm.     

The policy of surgery for small carcinoid tumors of the rectum

In this report, we discuss the current policy of surgery for small carcinoid tumors of the rectum, with reference to our own cases and also to those reported in the literature. Ten cases of rectal carcinoid tumors were surgically treated at the National Kyushu Cancer Center over a period of sixteen years and three months. The tumors ranged in size from 0.2 to 1.0 cm, with an average of 0.5 cm, and all were confined to the submucosa. The lesions were treated by local excision in eight patients and by low anterior resection in the other two cases, where transanal or transsacral excision was considered difficult. No lymph node involvement was found in these two cases. All patients are alive and well without recurrence, after a average follow-up time of three years and six months. According to the literature, the incidence of metastasis from rectal carcinoid tumors smaller than 1 cm is very low, ranging between 1.7 to 3.4 per cent, and it therefore seems that most such lesions can be treated by local excision alone. If, however, any muscle invasion or lymphatic vessel invasion is demonstrated, then radical surgery is recommended.     

The policy of surgery for small carcinoid tumors of the rectum

In this report, we discuss the current policy of surgery for small carcinoid tumors of the rectum, with reference to our own cases and also to those reported in the literature. Ten cases of rectal carcinoid tumors were surgically treated at the National Kyushu Cancer Center over a period of sixteen years and three months. The tumors ranged in size from 0.2 to 1.0 cm, with an average of 0.5 cm, and all were confined to the submucosa. The lesions were treated by local excision in eight patients and by low anterior resection in the other two cases, where transanal or transsacral excision was considered difficult. No lymph node involvement was found in these two cases. All patients are alive and well without recurrence, after an average follow-up time of three years and six months. According to the literature, the incidence of metastasis from rectal carcinoid tumors smaller than 1 cm is very low, ranging between 1.7 to 3.4 per cent, and it therefore seems that most such lesions can be treated by local excision alone. If, however, any muscle invasion or lymphatic vessel invasion is demonstrated, then radical surgery is recommended.     

Variables related to risk of recurrence in rectal cancer without lymph node metastasis

Background: There has been recent interest in the use of local excision for rectal cancer under consideration of patient's quality of life. However, local excision of the primary tumor does not remove the areas of lymphatic spread. Therefore, the decision to use this procedure must be considered carefully. Methods: The authors retrospectively analyzed 142 patients who underwent radical resection of rectal cancer without lymph node metastasis in order to define the risk factors for recurrence. The macroscopic and microscopic pathological characteristics, immunohistochemical staining for p53, and DNA ploidy pattern of the primary tumor were examined as potential predictors of recurrence. Results: The rates for 5-year disease-free survival, local control, freedom from distant metastasis, and overall survival in these 142 patients were 87%, 93%, 93%, and 91%, respectively. Factors related to recurrence and prognosis included the depth of tumor invasion, vascular/lymphatic involvement, tumor differentiation, and tumor size. However, p53 staining and DNA ploidy pattern were not useful indicators. Conclusions: Our findings suggest that adjunctive radiotherapy and chemotherapy should be considered for patients who have rectal cancer without lymph node metastasis in the following situations: tumor invasion of the serosa, vascular/lymphatic involvement, moderately differentiated adenocarcinoma, and lesions >2 cm in diameter. Local excision should not be used in these situations, even if there are no lymph node metastases. The results of this study were presented at the 46th Annual Cancer Symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Is Total Mesorectal Excision Always Necessary for T1–T2 Lower Rectal Cancer?

Background

The goal of this multicenter study was to clarify the determinants of local excision for patients with T1–T2 lower rectal cancer.

Methods

Data from 567 consecutive patients who underwent radical resection for T1–T2 lower rectal cancer at 12 institutions between 1991 and 1998 were reviewed. Rates of lymph node metastasis were investigated using a tree analysis, which was hierarchized using independent risk factors for nodal involvement.

Results

The independent risk factors for lymph node metastasis were female gender, depth of tumor invasion, histology other than well-differentiated adenocarcinoma, and lymphatic invasion. According to the first three parameters that can be obtained preoperatively, only 0.99% of the patients without risk factors had lymph node metastasis. On the other hand, even if the lower rectal cancer was at stage T1, women with histological types other than well-differentiated adenocarcinoma had an approximately 30% probability of having lymph node metastasis. Lymphatic invasion was most useful to predict nodal involvement among patients with T2 lower rectal cancer. The rates of lymph node metastasis in T2 patients with and without lymphatic invasion were 32.9% and 9.1%, respectively.

Conclusions

Gender is one of the most important predictors for lymph node metastasis in patients with early distal rectal cancer. Three parameters, including depth of tumor invasion, histology, and gender, are useful determinants for local excision. Additional studies are required to establish the minimum optimal treatment for T2 lower rectal cancer.     

T2期直肠癌淋巴结转移相关影响因素

目的探讨影响T2期直肠癌淋巴结转移的临床病理因素。方法回顾分析福建医科大学附属第一医院2006年3月至2011年1月间行根治性切除的122例T2期直肠癌患者的临床资料,分析影响其淋巴结转移的相关临床病理因素。结果122例T2期直肠癌患者中有26例（21．3％）发生淋巴结转移。单因素分析显示,肿瘤距肛缘距离（P〈0.05）、大体类型（P〈0.05）、组织类型（P〈0．01）、分化程度（P〈0．05）及肿瘤浸润深度（P〈0．05）与T2期直肠癌淋巴结转移有关。多因素分析显示,肿瘤浸润深度是影响T2期直肠癌淋巴结转移的独立因素（P〈0.05）;直肠癌浸润浅肌层和深肌层者淋巴结转移率分别为13．0％（7／54）和27．9％（19／68）。结论对于局限于浅肌层的L期直肠癌,因其淋巴结转移率较低,可考虑行经肛局部切除手术。     

Predictive factors for lymph node metastasis in early gastric cancer with submucosal invasion: analysis of a single institutional experience

OBJECTIVE: An accurate assessment of a potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the amount of invasive procedures used in cancer treatment is critical for improving the patient's quality of life. Therefore, this study analyzed the predictive risk factors for a lymph node metastasis in early gastric cancer with a submucosal invasion. METHODS: The data from 1043 patients surgically treated for early gastric cancer with submucosal invasion between 2002 and 2005 were reviewed retrospectively. The patients were divided into 3 layers according to their depth: SM1, SM2, and SM3. The clinicopathological variables predicting a lymph node metastasis were evaluated. RESULTS: A lymph node metastasis was observed in 19.4% of patients. The tumor size, histologic type, Lauren classification, tumor depth, and perineural invasion showed a positive correlation with the rate of lymph node metastasis and N category by univariate analysis. Multivariate analyses revealed the tumor size (>or=2 cm) and lymphatic involvement to be significantly and independently related to lymph node metastasis. The presence of lymphatic involvement was the strongest predictive factor for a lymph node metastasis, being observed in 43.8% of cases in which a lymph node metastasis had been revealed. No lymph node metastasis was observed in the 12 cases with no lymphatic involvement, SM1 invasion, and tumor size <1 cm. CONCLUSIONS: Lymphatic involvement and tumor size are independent risk factors for a lymph node metastasis in early gastric cancer with submucosal invasion. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible in highly selective submucosal cancers with no lymphatic involvement, SM1 invasion, and tumor size <1 cm.     

Carcinoid tumors of the gastrointestinal tract

Carcinoid tumors continue to be of specific clinical interest because of their diverse presentation, hormonal secretion, and malignant potential. One hundred ninety-two patients with carcinoid tumors were treated at the University of Iowa Hospitals and Clinics between 1938 and 1982. The most common location of these tumors was the appendix (30%), followed by the ileum (23%) and rectum (9%). Metastatic disease occurred in 29 per cent of all patients, with colonic and ileal tumors being the most likely to metastasize (40% and 35%, respectively). Surgical excision continues to be the treatment of choice in resectable tumors. Appendectomy alone proved effective in the treatment of appendiceal tumors less than 2 cm in diameter and without lymph node metastases. Local excision was also sufficient for the treatment of rectal tumors less than 2 cm in diameter and without invasion of the muscularis propria. Ileal, colonic, and locally advanced appendiceal and rectal tumors should be treated with radical excision including resection of the regional lymph nodes. The overall 5-year survival rate was 47%. Patients with metastatic disease had a lower survival rate (25%) compared with patients without metastases (64%).     

Anorectal carcinoid tumors. Is aggressive surgery warranted?

The management of large carcinoid tumors of the anorectum is controversial. Most carcinoid tumors of the rectum and anus are early lesions, adequately treated by local excision. However, because of their relative rarity, the number of advanced cases seen at most institutions is small. Forty-three patients with anorectal carcinoid tumors were treated at our institution between 1960 and 1988 with complete follow-up. The median age of onset was 56 years. Eleven patients had no symptoms and the tumor was detected incidentally in eight additional patients with other diseases. Twenty tumors were larger than 2 cm in diameter and all patients had symptoms. Eight patients had another malignancy and three patients had ulcerative colitis. An association between ulcerative colitis and rectal carcinoid tumors is not widely appreciated. Eighteen tumors were treated by local excision, 16 by radical surgery, and nine underwent only biopsy. With complete resection of the primary lesion, local recurrence was never a problem. The median survival from diagnosis was 38 months in this series and 23 patients died of disease. After detection of metastases, the median survival time was 10 months. Tumors more advanced that T2 or larger than 2 cm in diameter were always fatal. All 13 patients with involved lymph nodes died of metastatic disease, with a median survival of 10 months, although one lived 9 years. Advanced rectal carcinoid tumors are aggressive malignancies. Adequate local excision controls regional disease but rectal carcinoid tumors are cured only when they are discovered before the T3 stage, measure less than 2 cm in diameter, and when lymph nodes are not involved. Consequently if a local excision permits complete resection, radical extirpative surgery will provide little benefit.     

Hilar lymph node metastasis in renal cell carcinoma.

A 48-year-old man, who underwent a right nephrectomy for renal cell carcinoma 7 years earlier, was found to have hilar lymph node metastasis alone, without lesions, in the pulmonary parenchyma. Chest X-ray and CT findings showed a left hilar mass about 4 x 2.5 cm in diameter. Left bronchial arteriography showed a hypervascular mass lesion in the left hilum. Macroscopic tumor invasion of the pulmonary artery and left main bronchus indicated left pneumonectomy. The resected specimen was found histologically to involve metastatic renal cell carcinoma in the left hilar lymph node about 3 cm in diameter. Tumor metastasis was limited to the lymph node. The metastatic pathway of renal cell carcinoma to the hilar lymph node was considered lymphogenous via either retrograde lymphatic flow from the thoracic duct or through the lymphatics in the inferior pulmonary ligament.     

Clinicopathological study on the intramural metastasis of the esophageal cancer

Intramural metastasis and microscopical lymphatic permeation (distant-ly) distant more than 5mm from primary lesion were evaluated clinicopathologically in 207 patients with esophageal cancer, to reveal intramural lymphatic metastasis in esophageal cancer. Thirty-one lesions of intramural metastasis in 21 patients (10%) and 85 distant-ly lesions in 19 patients (9%) were observed. Both lesions existed mainly in lpm or sm layer and located within 5cm from primary lesion. As a direction of metastasis, intramural metastasis existed almost equivalently oral and anal from primary lesion, but distant-ly existed slightly more frequently in anal direction. When intramural metastatic lesion was recognized oral from primary lesion, lymph node involvement of the upper mediastinum was present in 67% of cases. On the other hand, intramural metastasis was seen anal from primary lesion and lymph node involvement of upper paragastric region was present in 100% of cases. Patients with intramural metastasis showed poor prognosis of one year of 50% survival period.     

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.     

大肠类癌的诊断与治疗

目的探讨结直肠类癌的预后因素及外科治疗方法的选择.方法回顾性分析1990～1999年经我院治疗的46例结直肠类癌的临床资料.结果大肠类癌男女之比为1.4∶1.直肠类癌发病率高(83%,38/46),肿瘤体积小(直径<2*!cm者占82%,31/38),预后较好.肿瘤直径大于2*!cm的直肠类癌转移率为71%(5/7),平均生存时间25个月.结肠类癌发现晚,转移发生早,转移率为83%(5/6),大于2*!cm结肠类癌平均生存时间18个月.结论结直肠类癌的大小,有无浸润及远处转移,是判断结直肠类癌良恶性、决定手术方式和预后的主要依据.     

Histopathologic Criteria for Local Excision of Colorectal Cancer: Multivariate Analysis

Background: Local treatment of colorectal cancer, including endoscopic removal of colonic polyps and transanal resection of rectal tumors, has become widely accepted. However, risk factors predicting the presence of lymph node metastasis have not been fully investigated. To determine the criteria for local excision of colorectal cancer, histopathologic factors independently predicting the lymph node metastasis were investigated.Methods: We performed a retrospective histopathologic study on 335 patients who underwent resection of colorectal cancer and dissection of regional lymph nodes between 1982 and 1996. Features of node-positive tumors (n = 150) were compared with those of node-negative tumors (n = 185), with special reference to the histopathologic findings of the resected tumor. Multivariate analysis was done using the stepwise logistic regression test.Results: Node-positive tumors, when compared with node-negative tumors, were characterized by tumor larger than 6 cm (42% vs. 22%), serosal invasion (88% vs. 56%), lymphatic invasion (32% vs. 5%), venous invasion (9% vs. 2%), and histology other than well-differentiated (66% vs. 29%). Multivariate analysis showed that factors independently associated with lymph node metastasis were serosal invasion, lymphatic invasion, and histologic type. When these three risk factors were negative, lymph node metastasis was rare (5%). When one, two, or three factors were positive, the frequency of lymph node metastasis was 38%, 66%, and 85%, respectively.Conclusions: In colorectal cancer, factors independently associated with lymph node metastasis are serosal invasion, lymphatic invasion, and histologic type. When these three parameters are favorable, local treatment of colorectal cancer does not require additional lymph node dissection.     

直肠肿瘤局部切除术在直肠癌治疗中的应用

直肠癌局部切除适用于肿瘤直径≤3cm,高中分化腺癌,浸润深度为黏膜或黏膜下,无淋巴结转移。直肠癌分期明显影响着直肠癌局部切除术后的存活率。     

292例早期胃癌淋巴结转移规律的研究

目的分析早期胃癌淋巴结转移规律,为合理选择手术方式提供依据。方法选择施行根治手术、临床病理资料完整、检取淋巴结总数在15枚以上的292例早期胃癌患者为研究对象,分析各站、号淋巴结转移率及其影响因素。结果所有患者淋巴结转移率为14．7％,其中黏膜内癌为6．4％,黏膜下癌为22．4％。多因素分析表明：浸润深度、淋巴管癌栓是影响早期胃癌淋巴结转移的独立危险因素。各站、号淋巴结转移率为：第Ⅰ站12．7％,频率由高到低依次为第6、3、4、1、5号淋巴结;第Ⅱ站7．2％,频率依次为第7、8a号淋巴结;第Ⅲ站0．34％。癌灶最大长径≤2．0cm伴淋巴结转移的早期胃癌均为凹陷型;伴淋巴结转移的隆起型早期胃癌最大长径均≥3．0cm。结论癌灶最大长径≤2．0cm、隆起型、黏膜内癌应行缩小手术;癌灶最大长径≤3．0cm的凹陷型或〉3．0cm的隆起型应行D1＋第7、8a号淋巴结清除术;对于〉3．0cm的凹陷型癌应选择标准根治术（D2）为宜。     

A case of mucosal esophageal carcinoma with a large intramural metastasis in the stomach

The prognosis of mucosal carcinoma of the esophagus is extremely good because of low frequency of lymphatic invasion compared with submucosal carcinoma. A 64-year-old male was admitted presented with dysphagia and weight loss. Roentgenogram and esophagoscopy revealed erosive lesions in the lower portion of the esophagus and a huge submucosal tumor that looked like the myosarcoma in the cardial portion. After total resection of thoracic esophagus and partial gastrectomy, esophagogastrostomy was done through the anterior thoracic route. During the operation, we found a few disseminative foci in the thoracic cavity (pl1) and direct invasion of cardial tumor to the celiac portion. Therefore, the operation was absolute by palliative. Histological examination of the resected specimen showed that the IIc-like lesion of the lower portion of the esophagus was a moderately differentiated squamous cell carcinoma invading the mucosa (mm), which was 2.0 x 1.6 cm in size, with marked lymphatic invasion, and intra-mural metastatic foci (7.0 x 5.0 cm) at the cardial portion. The patient died 3 months after the operation with mediastinal lymph node metastasis. In our 19 cases of resected mucosal carcinoma of the esophagus, lymphatic invasion was positive in 16%, and lymph node metastasis was positive in 16%, and intramural metastasis was in only one case. Frequency of intramural metastasis in esophageal carcinoma is about 10% in sm -a3 lesion, 5% in mm. In our experience, the prognosis of curatively resected mucosal carcinoma of the esophagus is generally good. We get long survivals, when curative operation is undergone, even if the lymphatic invasion is positive.     

早期远端胃印戒细胞癌淋巴结转移的危险因素分析及外科手术指征探讨

目的研究早期远端胃印戒细胞癌淋巴结转移的危险因素,进一步分析其外科手术指征。方法回顾性分析2013年3月至2018年11月期间在苏州大学附属第一医院普外科接受外科根治手术且术后病理学检查证实为远端胃印戒细胞癌的91例早期胃癌患者的临床资料,收集患者的性别、年龄、肿瘤最大径、病灶数量、浸润深度、肿瘤大体外观、脉管癌栓、合并溃疡等数据,探索发生淋巴结转移的危险因素,进一步分析外科手术指征。结果91例早期远端胃印戒细胞癌均接受了外科根治性手术,其中淋巴结转移10例。单因素分析结果显示,肿瘤最大径(χ^2=5.631,P=0.025)、浸润深度(χ^2=4.389,P=0.016)、病灶数量(χ^2=5.615,P=0.023)及脉管癌栓(χ^2=22.500,P=0.001)均与早期远端胃印戒细胞癌的淋巴结转移有关。多因素分析结果显示,肿瘤最大径(OR=3.675,P=0.012)、浸润深度(OR=3.886,P=0.015)及脉管癌栓(OR=8.711,P<0.001)是早期远端胃印戒细胞癌发生淋巴结转移的影响因素,肿瘤最大径≥2 cm、浸润至黏膜下层及有脉管癌栓的患者有更高的淋巴结转移率。结论肿瘤最大径≥2 cm、浸润至黏膜下层及存在脉管癌栓的早期远端胃印戒细胞癌患者有更高的淋巴结转移风险;满足肿瘤最大径≥2 cm和存在脉管癌栓中任何1项条件者均可能需接受外科根治性手术。     

Lymph-node metastases in rectal carcinoids

Background

Colorectal carcinoids are described as low-grade malignancy in the WHO classification. However, the survival is equally poor between carcinoids and adenocarcinomas if the tumors have lymph node metastasis or distant metastasis.

Patients and methods

We reviewed 17 patients with rectal carcinoid, who underwent surgical resection with lymph node dissection at our institution between March 2005 and November 2007. Our criteria for surgical resection were: tumor size of 10 mm or larger and positive resection margin or the presence of lymphovascular invasion in lesions to which endoscopic or surgical local treatment was carried out.

Results

Lymph node metastases were present in 12 patients. Three of them were with tumors less than 10 mm in size, of whom two patients had lymphovascular invasion. In eight out of the 12 with lymph node metastases, preoperative computed tomography (CT) identified lymph nodes of 5 mm or larger in size.

Conclusions

The present study demonstrated that rectal carcinoids with lymph node metastasis are common. Previously reported risk factors of lymph node metastasis in rectal carcinoid such as tumor size >?=?10 mm and lymphovascular invasion are useful in predicting lymph node metastasis. In addition, lymph nodes 5 mm or larger in size identified on preoperative CT suggest the presence of metastasis.