LATE TUMOR PROGRESSION: SYSTEMIC METASTASIS AND PERINEAL RECURRENCE AFTER ABDOMINOPERINEAL RESECTION OF THE RECTUM

Case Presentation A 63-year-old male with stage II/III mid-rectal adenocarcinoma underwent neoadjuvant therapy in 2014 (5-fluorouracil and 5.4 Gy) achieving a complete clinical response. An organ-preservation protocol was followed for 18 months, after which a bleeding lesion was identified during rectoscopy, confirming tumor regrowth. The patient underwent abdominoperineal resection (APR) in 2016, with pathology showing ypT1N0. He remained under oncological follow-up without complications until 2022 (six years post-APR) when hepatic metastases developed. Segmentectomy (segments VII/VIII) was performed, followed by adjuvant therapy (capecitabine). Subsequently, a subcutaneous 1 cm perineal nodule appeared near the surgical scar, causing mild pain. Initially, clinical observation was chosen, but the lesion demonstrated slow growth and increasing local pain. In 2023, MRI and PET-CT revealed hypermetabolism (SUVmax = 10.4) at the perineal surgical scar. The nodule was surgically excised, and histopathology confirmed tubulovillous adenocarcinoma in fibroadipose tissue, with clear margins.

Discussion Local recurrence following surgical resection of rectal adenocarcinoma occurs in 3% to 35% of cases within five years. After APR, recurrence can present as pelviperineal, pelvic, or perineal. Perineal recurrence, although rarely described in isolation, can often be detected during physical examination. Neoadjuvant therapy plays an undeniable role in reducing local recurrence rates. However, both classical and total neoadjuvant therapies have shown late systemic and local recurrences, the pathological mechanism of which remains undefined. Surgical resection of systemic and local progression can achieve curative outcomes, emphasizing the importance of adequate oncological follow-up. In this case, the patient showed a good response to neoadjuvant therapy, achieving complete clinical response, enabling organ preservation. It is known that 30% of patients experience tumor regrowth, primarily within the first two years of post-treatment. The rarity of this case lies in the prolonged interval of both systemic and perineal recurrence (more than five years), with successful curative resections and histological confirmation.

Conclusion Prolonged and adequate oncological follow-up after multimodal treatment for rectal adenocarcinoma appears to be the best strategy to improve disease-free survival, as late recurrence is increasingly being documented.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025