Recurrence with isolated vaginal metastasis after comprehensive treatment of ulcerated moderately differentiated carcinoma of the lower rectum: A case report

Recurrence with isolated vaginal metastasis after comprehensive treatment of ulcerated moderately differentiated carcinoma of the lower rectum: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Recurrence with isolated vaginal metastasis after comprehensive treatment of ulcerated moderately differentiated carcinoma of the lower rectum: A case report LIxia Zhang, Xiaoling Jiang, Maoyuan Wu, Wenwen Zhang, Guanyan Wang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4291181/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Locally recurrent rectal cancer (LRRC) refers to the lesions that appear in the pelvic cavity and perineum with the same pathological type as the primary tumor after radical operation of rectal cancer, excluding other distant metastases such as liver, lung, and bone. Radical surgical resection in such patients is a central element in improving quality of life and survival. In this paper, we report the case of a patient who was admitted to our hospital with a recurrence of ulcerated moderately differentiated carcinoma of the lower rectum with vaginal involvement after comprehensive treatment. After discussion by a multidisciplinary team, surgical treatment was selected to be performed through a longitudinal incision approach in the prone position of the sacrum, with complete resection of the tumor tissues, which improved the patient's quality of life and increased her survival rate. local recurrence of rectal cancer vagina radical resection longitudinal incisional approach via the sacral prone position Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The common parts of local recurrence after comprehensive treatment for rectal cancer are mainly anastomosis, perineum, soft tissues in the pelvis and adjacent organs or structures. For different recurrence sites, treatment programs and surgical methods are different. Clinically, surgical operation is difficult due to the complexity of the pelvic anatomy and the disruption of normal anatomical structures by the first surgery or radiotherapy. Here, we report the diagnosis and management of a case of ulcerated moderately differentiated adenocarcinoma of the lower rectum with recurrence and vaginal involvement after comprehensive treatments. Case Presentation A 45-year-old female patient with "irregular vaginal discharge for 1+ months" was admitted to the hospital. One month ago, she presented with irregular vaginal discharge, which was yellowish, watery and occasionally bloody. Family history: Patients with a history of similar illnesses and a family genetic predisposition to diseases similar to the patient were excluded. Her history was as follows: 1+ years ago (April 2022), because of alternate changes in bowel symptoms, manifested as diarrhea and constipation alternately, an average of 3-4 times/day, accompanied by the thinning of stools, in a foreign hospital, except for contraindications to the operation, 2022-7-22 "laparoscopic perineum combined with radical resection of rectal cancer, sigmoid colostomy". During the operation, the tumor was located in the lateral posterior wall of the low rectum, approximately 5.5×4.6×1.3 cm in size, approximately 1.5 cm from the anal verge, and infiltrated to the dentate line, occupying 2/3 of the intestinal lumen. The tumor seemed to invade through the whole intestinal wall, and there was no obvious abnormality of the peritoneum of the pelvic floor. Multiple enlarged lymph nodes were observed around the inferior mesenteric vessels. Postoperative pathology revealed the following: rectal tumor resection specimen; ulcerated moderately differentiated adenocarcinoma with large necrosis; cancer invading the plasma membrane layer; and cancerous embolus and nerve invasion in the vasculature. No cancerous tissue was observed at the oral margins or anus margins, no cancerous tissue was detected in the pouch, and metastasis of cancerous tissue was detected in the peri-intestinal (2/18) lymph nodes. Pathological AJCC stage: pT4N1b. Six courses of chemotherapy (oxaliplatin + capecitabine) were administered between September 2022 and April 2023 after surgery, during which radiotherapy was administered after the second course of chemotherapy. The AFP, CEA, and CA19-9 levels were detected within the normal reference range during radiotherapy; pelvic MRI in February 2023 suggested a circular enhancing nodular shadow of approximately 1.0 cm in transverse diameter in the posterior aspect of the vagina, with no obvious diffusion restriction. In August 2023, he returned to the hospital for follow-up, and the tumor indicators were within the normal reference range. Pelvic MRI suggested that a ring-shaped nodular shadow with a transverse diameter of approximately 1.5 cm was seen present in the posterior part of the vagina, and diffusion was limited. Auxiliary examination: Positron emission tomography-computed tomography (PET/CT) revealed a mass with a soft tissue density shadow in the anal region, an unclear border, and unclear boundaries with the adjacent vagina. FDG-PET revealed increased radioactivity uptake, with an SUVmax of 14.1 and an SUVavg of 6.87, and the range of the largest region was approximately 3.6*3.4 cm. Involvement of the vagina was possible, and the remaining tissues and organs did not exhibit clear abnormal hypermetabolic foci. Pelvic Magnetic resonance imaging (MRI) + enhanced MRI revealed a ring-shaped intensified mass in the posterior vaginal wall, and the metastatic tumor was likely to be large. The posterior wall of the vagina had a transverse diameter of approximately 3.2×3.8 cm, the sagittal position of the circular ring-shaped intensified mass shadow was approximately 4.0 cm, the border was irregular and lobulated, and the burr was clearly visible (Figure 1A and B). Compared with the MRI image obtained on August 08, 2023, the nodule in the posterior wall of the vagina was obviously enlarged. Biopsy pathology of the posterior vaginal wall suggested (tissue of the posterior vaginal wall) a large amount of coagulative necrosis and a small amount of adenocarcinoma tissue. Laboratory tests revealed a squamous epithelial cell carcinoma antigen concentration of 0.8 ng/ml. After discussion by our multidisciplinary team, comprehensive assessment of the patient's local recurrence of tumor tissue could be performed via radical resection. On December 9, 2023, under anesthesia, tumor resection of the posterior vaginal wall + caudal osteotomy + bilateral gluteus maximus kite flap excision and transplantation was carried out, and the patient was placed in a prone position. When anesthesia was in effect, the towel was routinely disinfected and spread out, a longitudinal incision was made along the gluteal groove, up to the third sacrum, and down to the external portion of the vagina, and the subcutaneous tissue behind the coccyx was incised through the sacrum surface. The left hand entered the vagina, and the tumor was found to be located in the posterior wall of the vagina adhering to sacral vertebra 5 and the coccyx. The gluteus maximus muscle was dissected from the sacrococcygeal attachment point below sacral vertebra three, and sacral vertebra 5 was dissected. The anus tibialis muscle and the two sides of the vagina and the posterior wall were dissected under the guidance of the hand in the vagina at a distance of 3.0 cm from the tumor to retain the anterior wall of the vagina under the urethra, and the upper boundary reached the posterior fornix of the vagina. The tissues of the left and right sides were pulled toward the central defect of the pelvic floor, and the incision could not be sutured with high tension, so a tipped flap graft was generated. The gluteal midline was taken as the side length, and a symmetrical "triangle" mark was made on the surface of the gluteus maximus muscle on both sides, in which the skin and subcutis of the other two sides were incised to reach the gluteus maximus muscle. The superior gluteal artery was used as the tip of the flap, part of the gluteus maximus muscle was freed, the flap was cross-folded and filled into the incision, the excess skin was resected, the skin was closed, and a drainage tube was placed under the left and right sides of the vagina at the flaps. A drainage tube was placed under the right and left vaginal flaps (Figure 2). Postoperative pathology revealed adenocarcinoma. The immunohistochemistry results were as follows: CK8/18 (+), CK20 (+), CDX-2 (+), Villin (+), p16 (+), EGFR (+), P53 (-), CK7 (-), CD56 (-), CA125 (-), WT1 (-), ER (-), PR (-), CgA (foci +), Syn (-), and Ki-67 (+) (approximately 70%) (Figure 3). She returned to the outpatient clinic for review 38 days after the operation, and her examination showed that the operation area of the buttocks could be recovered. Pelvic MRI scanning + enhancement suggested postoperative changes after resection of the mass in the posterior vaginal wall, and part of the tailbone was missing; the rest of the patient did not show any abnormalities (Figure 1C and D). Discussion and Conclusions With the extensive multidisciplinary and comprehensive treatment of rectal cancer, thelocal recurrence rate of rectal cancer has decreased to less than 10% [1, 2]. Locally recurrent recta cancer (LRRC) refers to foci that appear in the pelvis and perineum region with the same pathologic type as the primary tumor after radical surgery for rectal cancer, excluding the accompanying other distant transitions, such as liver, lungs and bones. The common sites of local recurrence are mainly the anastomosis, perineum, soft tissues in the pelvis and adjacent organs or structures. Due to the heterogeneity of the patient population, different clinical manifestations, and different sites of recurrent tumor tissue invasion, there is a lack of standardized diagnostic and therapeutic procedures for the diagnosis, treatment strategies, and surgical methods of LRRC. In recent years, studies at home and abroad have shown that the treatment of local recurrence in patients with rectal cancer should be individualized and based on a multidisciplinary team to carry out diagnosis and treatment [3], and radical surgical resection for local recurrence (R0 resection) is still the best choice for successful treatment of local recurrence [4]. Close follow-up after radical rectal cancer treatment is an important means to diagnose recurrence as early as possible, and regular tumor marker tests, imaging examinations and physical examinations are more important for patients with recurrence and no symptoms. In this case, the patient underwent radiotherapy and chemotherapy after radical treatment for rectal cancer, during which no obvious abnormalities were found in the tumor marker or CT. In February 2023, pelvic MRI suggested that a ring-shaped reinforced nodular shadow of approximately 1.0 cm in transverse diameter was observed in the posterior part of the vagina, and there was no obvious diffusion limitation. In August 2023, pelvic MRI suggested that a ring-shaped reinforced nodular shadow of approximately 1.5 cm in transverse diameter was observed in the posterior part of the vagina, and there was diffusion limitation. In November, the patient presented with irregular vaginal fluid symptoms. Perfect MRI suggested that the posterior wall of the vaginal ring-shaped strengthened mass was significantly larger than before, the border was irregular and lobulated, and burrs were observed. Additionally, metastatic tumors are likely when combined with the history. Secondary malignant tumors of the vagina can be confined to the vagina or not and can originate from the recurrence of primary malignant tumors of the vagina or from recurrent vaginal metastases of malignant tumors of other organs. Tumors originating from pelvic organs are mainly metastasized by implantation, direct infiltration, the lymphatic tract and hematogenous metastasis, while tumors originating from other sites are mainly metastasized by hematogenous metastasis. The rectum has no plasma membrane below the peritoneal reflex, and the tumor can easily infiltrate into the surrounding tissues after infiltrating the intestinal wall. It is generally believed that middle and low rectal cancers are more invasive. The patient in this case had moderately differentiated cancer of the lower rectum, the cancer tissue invaded the plasma layer, and a cancerous embolus in the vasculature and nerve invasion could be seen. For patients who experience recurrence and metastasis after radical surgery for rectal cancer, MRI and PET- CT are recommended for understanding the systemic condition and lesion site. Pelvic MRI can accurately show the extent of tumor invasion and determine the relationship between the tumor and adjacent structures [5]. PET-CT is better than Computed tomography (CT) and MRI for identifying tissue fibrosis and tumor recurrence, is a guide for the evaluation of local recurrence, and can also be used to evaluate distant metastasis [6]. Histopathological findings confirm that homology with previous tumor pathology is the gold standard for the diagnosis of recurrence, and biopsy is recommended to obtain histopathological evidence if possible [7]. Therefore, after the patient in this case presented with localized vaginal symptoms, pelvic MRI, PET-CT and histopathological examination of the biopsy of the posterior vaginal wall were perfected, suggesting that the shadow of the ring- enhanced mass in the posterior vaginal wall had increased significantly compared with that of the previous mass, and biopsy of the posterior vaginal wall suggested that adenocarcinoma was present. In patients with localized recurrence after comprehensive treatment for rectal cancer, several studies have shown that radical resection (R0 resection) is an independent factor influencing survival in patients with localized recurrence [3, 8, 9]. As the only curative treatment for patients with localized recurrence of rectal cancer, radical resection is important for potentially curable patients. Direct surgical resection is recommended for patients with a history of pelvic radiotherapy for isolated tumors without distant metastases and locally resectable tumors [10]. Based on the relevant examination results, a multidisciplinary team discussion was held to assess the R0 surgical resectability and surgical risk, determine the surgical access, choose the surgical procedure and the scope of resection, and adequately plan the surgery to minimize the occurrence of postoperative complications. If the boundary of the lesion is unclear, the infiltration range is wide, it is difficult to resect cleanly by surgery, or the patient has absolute contraindications to radical surgery (such as severe cardiopulmonary dysfunction unable to tolerate surgery, bilateral sciatic nerves invaded by the tumor, external iliac blood vessels involved, pelvic wall invasion, etc.) [11], in those cases, surgery should not be performed blindly, and preoperative combined radiotherapy and chemotherapy should be performed so as to strive for the chance of surgery. Due to the complexity of the pelvic anatomy and the destruction of the normal anatomical structure by the first surgery or radiotherapy, the traditional transabdominal or transabdominal perineal combined approach is difficult to perform, and the unclear surgical field, anatomical structure disorder, local adhesions, tumor infiltration, and roughness of the operation can increase the difficulty of the surgery, the intraoperative damage to the neighboring organs in the urinary tract, the risk of bleeding, and the difficulty of precise hemostasis. Therefore, improving surgical access, ensuring the curative nature of surgery as much as possible, shortening the operation time, and reducing the occurrence of complications have become the core of treatment. Adequate exposure of the surgical field is a prerequisite for ensuring complete resection of tumor tissue and avoiding pelvic organ damage, so the patient in this case underwent a longitudinal incision via the sacral prone position. The patient was placed in the prone position, the incision was made parallel to the gluteal sulcus, 2 cm lateral to it, or via the gluteal sulcus, and the incision was prolonged under the buttocks if necessary. The skin and subcutaneous tissues are incised, the gluteus maximus muscle and part of the anal retinaculum muscle are dissected at the attachment of the spine below the 4th sacral vertebra, and the branches of the inferior gluteal artery, the inferior gluteal nerve, and the branches of the subanal (rectal) and perineal nerves are cut off in this area. Intraoperative care is required to protect the urinary tract. The tip of the tailbone was dissected, and the fascia of the inferior border of the gluteus maximus muscle and the inferior gluteal cutaneous nerve were incised on both sides. The gluteal muscles are pulled back to the sides to expose the tumor tissue, the coccyx or part of the sacrum (sacrum below sacral 3) is resected if necessary to expose the operative field, and the tumor is resected 3 cm from the outer edge of the tumor under finger guidance. Reconstruction of the operative area is required to fill the presacral defect, promote surgical wound repair, and prevent surgical complications. Intraoperative flaps can be designed by selecting bilateral gluteus maximus muscles, with paired “kite” flaps on both sides, preserving the superior gluteal artery, and embedding them to cover the trauma completely. The use of muscle flaps for reconstruction results in better vascularization and reconstruction [12]. The use of a muscle flap for reconstruction results in better vascularization and reconstruction. A longitudinal incision via the sacrum in the prone position reduces tissue damage, decreases the degree of organ function destruction, and in case of intraoperative bleeding, a good view also facilitates hemostasis. If the incision is too tight to be sutured, then a flap graft with a tipped flap can be used to fill the incision with a free part of the gluteus maximus flap, and the skin can be sutured. In addition, the prone longitudinal incision approach is also suitable for patients with presacral cysts whose upper pole is lower than the level of the 4th sacral vertebra, cysts that are biased on the sacral side, and presacral cysts whose lower pole is closely related to the tip of the coccyx and the anorectal ring [13]. In this case, the patient underwent complete resection of the tumor tissue through this approach, and postoperative recovery of the incision was possible. Complete resection of locally recurrent tumor tissue is central to improving patients’ quality of life and prolonging survival. There is a lack of large-sample clinical randomized controlled studies on the prognostic impact of adjuvant therapy on the local recurrence of rectal cancer. Whether to administer adjuvant therapy after surgery needs to be discussed by a multidisciplinary team in conjunction with postoperative pathological and histochemical results and imaging findings. Currently, radical surgical options for local recurrence of rectal cancer are still undergoing continuous exploration to ensure radical surgical resection while minimizing complications and improving patients’ quality of life. For patients with local recurrence involving the vagina after comprehensive treatment of rectal cancer, if the possibility of radical resection is evaluated after discussion by a multidisciplinary team, in addition to the traditional transabdominal or combined transabdominal-perineal approach, the longitudinal incision approach through the prone position of the sacrum is also an option, which can successfully resect the tumor in a complete manner, reduce the difficulty of the operation, and prolong the patient’s survival period. This surgical approach does not require special medical equipment, and clinicians need to fully understand the anatomical structure, which makes it easy to promote its application. Abbreviations Locally recurrent rectal cancer (LRRC) Positron emission tomography-computed tomography (PET- CT) Magnetic resonance imaging (MRI) Computed Tomography (CT) Declarations All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher . Ethics approval and consent to participate Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants’ legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. Consent for publication All authors of the manuscript have read and agreed to its content and are accountable for all aspects of the accuracy and integrity of the manuscript in accordance with ICMJE criteria. That the article is original, has not already been published in a journal, and is not currently under consideration by another journal. The authors have agreed and signed an informed consent form with the patient in the case, and the patient gave informed consent. Availability of data and materials The original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author. Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by Grants Provided by Guizhou Provincial Science and Technology Agency (Qiankehe Jichu–ZK2022–No.580), and Zunyi Science and Technology Bureau (Zunshikehe–HZ2022–No.56). Authors’ contributions LZ: Investigation, Writing – original draft, Resources. LH: Writing – review & editing. XJ: Writing – review & editing. MW: Writing – review & editing. WZ: Writing – review & editing. GW: Writing – review & editing. WY: Writing – review & editing. TL: Writing – review & editing. GW: Writing – review & editing. Acknowledgements We thank our colleagues for their help. We acknowledge the patient’s contributions to the study. Per journal guidelines, all manuscripts reporting studies involving human participants, human data or human tissue must include a statement on ethics approval and consent (even where the need for approval was waived). 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Please use the authors’ initials to refer to each author's contribution. For example, "FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney and was a major contributor in writing the manuscript. All authors read and approved the final manuscript." Per journal guidelines, please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials. If you do not have anyone to acknowledge, please write "Not applicable" in this section. References Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol. 2020;17:414-29. Zaborowski A, Stakelum A, Winter DC. Systematic review of outcomes after total neoadjuvant therapy for locally advanced rectal cancer. Br J Surg. 2019;106:979-87. 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Multiple surgical approaches and anatomy for the resection of presacral cysts. Chin J Anat Clin. 2023;8:419-22. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4291181","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":293056416,"identity":"967409d2-63df-45c3-9d59-701caeb2c7f1","order_by":0,"name":"LIxia Zhang","email":"","orcid":"","institution":"Zunyi Medical University","correspondingAuthor":false,"prefix":"","firstName":"LIxia","middleName":"","lastName":"Zhang","suffix":""},{"id":293056417,"identity":"3a784715-d75f-4a57-854a-b31badd1f898","order_by":1,"name":"Xiaoling Jiang","email":"","orcid":"","institution":"Zunyi Medical 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University","correspondingAuthor":false,"prefix":"","firstName":"Gangcheng","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-04-19 06:23:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4291181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4291181/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55516569,"identity":"24896ab2-dc15-471b-9e84-b418074427b5","added_by":"auto","created_at":"2024-04-29 13:17:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":627949,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4291181/v1/8b7ca3504e05389d48f9ef8c.png"},{"id":55516570,"identity":"c20904f1-6b52-45f5-9394-8f8d774eda99","added_by":"auto","created_at":"2024-04-29 13:17:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":764808,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4291181/v1/f082b7b5b6e3562b9a388c28.png"},{"id":55516571,"identity":"232d47ac-aba5-483f-9f9f-819251284dc6","added_by":"auto","created_at":"2024-04-29 13:17:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":560351,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4291181/v1/30f29454f6595a66b674df16.png"},{"id":55516568,"identity":"1136df53-246e-4592-97fe-69494fec1a36","added_by":"auto","created_at":"2024-04-29 13:17:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":82031,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"file.png","url":"https://assets-eu.researchsquare.com/files/rs-4291181/v1/39a38158f6e20fa25a436156.png"},{"id":55519156,"identity":"693bd804-7c68-464c-8175-517f9dd13fa3","added_by":"auto","created_at":"2024-04-29 13:41:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2813021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4291181/v1/e2181dc8-5430-4b89-851e-332bcc06dd90.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Recurrence with isolated vaginal metastasis after comprehensive treatment of ulcerated moderately differentiated carcinoma of the lower rectum: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eThe common parts of local recurrence after comprehensive treatment for rectal cancer are mainly anastomosis, perineum, soft tissues in the pelvis and adjacent organs or structures. For different recurrence sites, treatment programs and surgical methods are different. Clinically, surgical operation is difficult due to the complexity of the pelvic anatomy and the disruption of normal anatomical structures by the first surgery or radiotherapy. Here, we report the diagnosis and management of a case of ulcerated moderately differentiated adenocarcinoma of the lower rectum with recurrence and vaginal involvement after comprehensive treatments.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA\u0026nbsp;45-year-old female patient with \u0026quot;irregular vaginal discharge for 1+ months\u0026quot; was admitted to the hospital. One month ago, she presented with irregular vaginal discharge, which was yellowish, watery and occasionally bloody. Family history: Patients with a history of similar illnesses and a family genetic predisposition to diseases similar to the patient were excluded.\u003c/p\u003e\n\u003cp\u003eHer\u0026nbsp;history was as follows: 1+ years ago (April 2022), because of alternate changes in bowel symptoms, manifested as diarrhea and constipation alternately, an average of 3-4 times/day, accompanied by the thinning of stools, in a foreign hospital, except for contraindications to the operation, 2022-7-22 \u0026quot;laparoscopic perineum combined with radical resection of rectal cancer, sigmoid colostomy\u0026quot;. During the operation, the tumor was located in the lateral posterior wall of the low rectum, approximately 5.5\u0026times;4.6\u0026times;1.3 cm in size, approximately 1.5 cm from the anal verge, and infiltrated to the dentate line, occupying 2/3 of the intestinal lumen. The tumor seemed to invade through the whole intestinal wall, and there was no obvious abnormality of the peritoneum of the pelvic floor. Multiple enlarged lymph nodes were observed around the inferior mesenteric vessels. Postoperative pathology revealed the following: rectal tumor resection specimen; ulcerated moderately differentiated adenocarcinoma with large necrosis; cancer invading the plasma membrane layer; and cancerous embolus and nerve invasion in the vasculature. No cancerous tissue was observed at the oral margins or anus margins, no cancerous tissue was detected in the pouch, and metastasis of cancerous tissue was detected in the peri-intestinal (2/18) lymph nodes. Pathological AJCC stage: pT4N1b. Six courses of chemotherapy (oxaliplatin + capecitabine) were administered between September 2022 and April 2023 after surgery, during which radiotherapy was administered after the second course of chemotherapy. The AFP, CEA, and CA19-9 levels were detected within the normal reference range during radiotherapy; pelvic MRI in February 2023 suggested a circular enhancing nodular shadow of approximately 1.0 cm in transverse diameter in the posterior aspect of the vagina, with no obvious diffusion restriction. In August 2023, he returned to the hospital for follow-up, and the tumor indicators were within the normal reference range. Pelvic MRI suggested that a ring-shaped nodular shadow with a transverse diameter of approximately 1.5 cm was seen present in the posterior part of the vagina, and diffusion was limited.\u003c/p\u003e\n\u003cp\u003eAuxiliary\u0026nbsp;examination: Positron emission tomography-computed tomography (PET/CT) revealed a mass with a soft tissue density shadow in the anal region, an unclear border, and unclear boundaries with the adjacent vagina. FDG-PET revealed increased radioactivity uptake, with an SUVmax of 14.1 and an SUVavg of 6.87, and the range of the largest region was approximately 3.6*3.4 cm. Involvement of the vagina was possible, and the remaining tissues and organs did not exhibit clear abnormal hypermetabolic foci. Pelvic Magnetic resonance imaging (MRI) + enhanced MRI revealed a ring-shaped intensified mass in the posterior vaginal wall, and the metastatic tumor was likely to be large. The posterior wall of the vagina had a transverse diameter of approximately 3.2\u0026times;3.8 cm, the sagittal position of the circular ring-shaped intensified mass shadow was approximately 4.0 cm, the border was irregular and lobulated, and the burr was clearly visible (Figure 1A and B). Compared with the MRI image obtained on August 08, 2023, the nodule in the posterior wall of the vagina was obviously enlarged. Biopsy pathology of the posterior vaginal wall suggested (tissue of the posterior vaginal wall) a large amount of coagulative necrosis and a small amount of adenocarcinoma tissue. Laboratory tests revealed a squamous epithelial cell carcinoma antigen concentration of 0.8 ng/ml.\u003c/p\u003e\n\u003cp\u003eAfter\u0026nbsp;discussion by our multidisciplinary team, comprehensive assessment of the patient\u0026apos;s local recurrence of tumor tissue could be performed via radical resection. On December 9, 2023, under anesthesia, tumor resection of the posterior vaginal wall + caudal osteotomy + bilateral gluteus maximus kite flap excision and transplantation was carried out, and the patient was placed in a prone position. When anesthesia was in effect, the towel was routinely disinfected and spread out, a longitudinal incision was made along the gluteal groove, up to the third sacrum, and down to the external portion of the vagina, and the subcutaneous tissue behind the coccyx was incised through the sacrum surface. The left hand entered the vagina, and the tumor was found to be located in the posterior wall of the vagina adhering to sacral vertebra 5 and the coccyx. The gluteus maximus muscle was dissected from the sacrococcygeal attachment point below sacral vertebra three, and sacral vertebra 5 was dissected. The anus tibialis muscle and the two sides of the vagina and the posterior wall were dissected under the guidance of the hand in the vagina at a distance of \u0026nbsp;3.0 cm from the tumor to retain the anterior wall of the vagina under the urethra, and the upper boundary reached the posterior fornix of the vagina. The tissues of the left and right sides were pulled toward the central defect of the pelvic floor, and the incision could not be sutured with high tension, so a tipped flap graft was generated. The gluteal midline was taken as the side length, and a symmetrical \u0026quot;triangle\u0026quot; mark was made on the surface of the gluteus maximus muscle on both sides, in which the skin and subcutis of the other two sides were incised to reach the gluteus maximus muscle. The superior gluteal artery was used as the tip of the flap, part of the gluteus maximus muscle was freed, the flap was cross-folded and filled into the incision, the excess skin was resected, the skin was closed, and a drainage tube was placed under the left and right sides of the vagina at the flaps. A drainage tube was placed under the right and left vaginal flaps (Figure 2).\u003c/p\u003e\n\u003cp\u003ePostoperative\u0026nbsp;pathology revealed adenocarcinoma. The immunohistochemistry results were as follows: CK8/18 (+), CK20 (+), CDX-2 (+), Villin (+), p16 (+), EGFR (+), P53 (-), CK7 (-), CD56 (-), CA125 (-), WT1 (-), ER (-), PR (-), CgA (foci +), Syn (-), and Ki-67 (+) (approximately 70%) (Figure 3).\u003c/p\u003e\n\u003cp\u003eShe\u0026nbsp;returned to the outpatient clinic for review 38 days after the operation, and her examination showed that the operation area of the buttocks could be recovered. Pelvic MRI scanning + enhancement suggested postoperative changes after resection of the mass in the posterior vaginal wall, and part of the tailbone was missing; the rest of the patient did not show any abnormalities (Figure 1C and D).\u003c/p\u003e\n"},{"header":"Discussion and Conclusions ","content":"\u003cp\u003eWith the extensive multidisciplinary and comprehensive treatment of rectal cancer, thelocal recurrence rate of rectal cancer has decreased to less than 10% [1, 2]. Locally recurrent recta cancer (LRRC) refers to foci that appear in the pelvis and perineum region with the same pathologic type as the primary tumor after radical surgery for rectal cancer, excluding the accompanying other distant transitions, such as liver, lungs and bones. The common sites of local recurrence are mainly the anastomosis, perineum, soft tissues in the pelvis and adjacent organs or structures. Due to the heterogeneity of the patient population, different clinical manifestations, and different sites of recurrent tumor tissue invasion, there is a lack of standardized diagnostic and therapeutic procedures for the diagnosis, treatment strategies, and surgical methods of LRRC. In recent years, studies at home and abroad have shown that the treatment of local recurrence in patients with rectal cancer should be individualized and based on a multidisciplinary team to carry out diagnosis and treatment [3], and radical surgical resection for local recurrence (R0 resection) is still the best choice for successful treatment of local recurrence [4].\u003c/p\u003e\n\u003cp\u003eClose\u0026nbsp;follow-up after radical rectal cancer treatment is an important means to diagnose recurrence as early as possible, and regular tumor marker tests, imaging examinations and physical examinations are more important for patients with recurrence and no symptoms. In this case, the patient underwent radiotherapy and chemotherapy after radical treatment for rectal cancer, during which no obvious abnormalities were found in the tumor marker or CT. In February 2023, pelvic MRI suggested that a ring-shaped reinforced nodular shadow of approximately 1.0 cm in transverse diameter was observed in the posterior part of the vagina, and there was no obvious diffusion limitation. In August 2023, pelvic MRI suggested that a ring-shaped reinforced nodular shadow of approximately 1.5 cm in transverse diameter was observed in the posterior part of the vagina, and there was diffusion limitation. In November, the patient presented with irregular vaginal fluid symptoms. Perfect MRI suggested that the posterior wall of the vaginal ring-shaped strengthened mass was significantly larger than before, the border was irregular and lobulated, and burrs were observed. Additionally, metastatic tumors are likely when combined with the history.\u003c/p\u003e\n\u003cp\u003eSecondary malignant tumors of the vagina can be confined to the vagina or not and can originate from the recurrence of primary malignant tumors of the vagina or from recurrent vaginal metastases of malignant tumors of other organs. Tumors originating from pelvic organs are mainly metastasized by implantation, direct infiltration, the lymphatic tract and hematogenous metastasis, while tumors originating from other sites are mainly metastasized by hematogenous metastasis. The rectum has no plasma membrane below the peritoneal reflex, and the tumor can easily infiltrate into the surrounding tissues after infiltrating the intestinal wall. It is generally believed that middle and low rectal cancers are more invasive. The patient in this case had moderately differentiated cancer of the lower rectum, the cancer tissue invaded the plasma layer, and a cancerous embolus in the vasculature and nerve invasion could be seen.\u003c/p\u003e\n\u003cp\u003eFor patients who experience recurrence and metastasis after radical surgery for rectal cancer, MRI and PET- CT are recommended for understanding the systemic condition and lesion site. Pelvic MRI can accurately show the extent of tumor invasion and determine the relationship between the tumor and adjacent structures [5]. PET-CT is better than Computed tomography (CT) and MRI for identifying tissue fibrosis and tumor recurrence, is a guide for the evaluation of local recurrence, and can also be used to evaluate distant metastasis [6]. Histopathological findings confirm that homology with previous tumor pathology is the gold standard for the diagnosis of recurrence, and biopsy is recommended to obtain histopathological evidence if possible [7]. Therefore, after the patient in this case presented with localized vaginal symptoms, pelvic MRI, PET-CT and histopathological examination of the biopsy of the posterior vaginal wall were perfected, suggesting that the shadow of the ring- enhanced mass in the posterior vaginal wall had increased significantly compared with that of the previous mass, and biopsy of the posterior vaginal wall suggested that adenocarcinoma was present.\u003c/p\u003e\n\u003cp\u003eIn patients with localized recurrence after comprehensive treatment for rectal cancer, several studies have shown that radical resection (R0 resection) is an independent factor influencing survival in patients with localized recurrence [3, 8, 9]. As the only curative treatment for patients with localized recurrence of rectal cancer, radical resection is important for potentially curable patients. Direct surgical resection is recommended for patients with a history of pelvic radiotherapy for isolated tumors without distant metastases and locally resectable tumors [10]. Based on the relevant examination results, a multidisciplinary team discussion was held to assess the R0 surgical resectability and surgical risk, determine the surgical access, choose the surgical procedure and the scope of resection, and adequately plan the surgery to minimize the occurrence of postoperative complications. If the boundary of the lesion is unclear, the infiltration range is wide, it is difficult to resect cleanly by surgery, or the patient has absolute contraindications to radical surgery (such as severe cardiopulmonary dysfunction unable to tolerate surgery, bilateral sciatic nerves invaded by the tumor, external iliac blood vessels involved, pelvic wall invasion, etc.) [11], in those cases, surgery should not be performed blindly, and preoperative combined radiotherapy and chemotherapy should be performed so as to strive for the chance of surgery.\u003c/p\u003e\n\u003cp\u003eDue to the complexity of the pelvic anatomy and the destruction of the normal anatomical structure by the first surgery or radiotherapy, the traditional transabdominal or transabdominal perineal combined approach is difficult to perform, and the unclear surgical field, anatomical structure disorder, local adhesions, tumor infiltration, and roughness of the operation can increase the difficulty of the surgery, the intraoperative damage to the neighboring organs in the urinary tract, the risk of bleeding, and the difficulty of precise hemostasis. Therefore, improving surgical access, ensuring the curative nature of surgery as much as possible, shortening the operation time, and reducing the occurrence of complications have become the core of treatment.\u003c/p\u003e\n\u003cp\u003eAdequate exposure of the surgical field is a prerequisite for ensuring complete resection of tumor tissue and avoiding pelvic organ damage, so the patient in this case underwent a longitudinal incision via the sacral prone position. The patient was placed in the prone position, the incision was made parallel to the gluteal sulcus, 2 cm lateral to it, or via the gluteal sulcus, and the incision was prolonged under the buttocks if necessary. The skin and subcutaneous tissues are incised, the gluteus maximus muscle and part of the anal retinaculum muscle are dissected at the attachment of the spine below the 4th sacral vertebra, and the branches of the inferior gluteal artery, the inferior gluteal nerve, and the branches of the subanal (rectal) and perineal nerves are cut off in this area. Intraoperative care is required to protect the urinary tract. The tip of the tailbone was dissected, and the fascia of the inferior border of the gluteus maximus muscle and the inferior gluteal cutaneous nerve were incised on both sides. The gluteal muscles are pulled back to the sides to expose the tumor tissue, the coccyx or part of the sacrum (sacrum below sacral 3) is resected if necessary to expose the operative field, and the tumor is resected 3 cm from the outer edge of the tumor under finger guidance. Reconstruction of the operative area is required to fill the presacral defect, promote surgical wound repair, and prevent surgical complications. Intraoperative flaps can be designed by selecting bilateral gluteus maximus muscles, with paired \u0026ldquo;kite\u0026rdquo; flaps on both sides, preserving the superior gluteal artery, and embedding them to cover the trauma completely. The use of muscle flaps for reconstruction results in better vascularization and reconstruction [12]. The use of a muscle flap for reconstruction results in better vascularization and reconstruction.\u003c/p\u003e\n\u003cp\u003eA longitudinal incision via the sacrum in the prone position reduces tissue damage, decreases the degree of organ function destruction, and in case of intraoperative bleeding, a good view also facilitates hemostasis. If the incision is too tight to be sutured, then a flap graft with a tipped flap can be used to fill the incision with a free part of the gluteus maximus flap, and the skin can be sutured. In addition, the prone longitudinal incision approach is also suitable for patients with presacral cysts whose upper pole is lower than the level of the 4th sacral vertebra, cysts that are biased on the sacral side, and presacral cysts whose lower pole is closely related to the tip of the coccyx and the anorectal ring [13]. In this case, the patient underwent complete resection of the tumor tissue through this approach, and postoperative recovery of the incision was possible.\u003c/p\u003e\n\u003cp\u003eComplete resection of locally recurrent tumor tissue is central to improving patients\u0026rsquo; quality of life and prolonging survival. There is a lack of large-sample clinical randomized controlled studies on the prognostic impact of adjuvant therapy on the local recurrence of rectal cancer. Whether to administer adjuvant therapy after surgery needs to be discussed by a multidisciplinary team in conjunction with postoperative pathological and histochemical results and imaging findings. Currently, radical surgical options for local recurrence of rectal cancer are still undergoing continuous exploration to ensure radical surgical resection while minimizing complications and improving patients\u0026rsquo; quality of life. For patients with local recurrence involving the vagina after comprehensive treatment of rectal cancer, if the possibility of radical resection is evaluated after discussion by a multidisciplinary team, in addition to the traditional transabdominal or combined transabdominal-perineal approach, the longitudinal incision approach through the prone position of the sacrum is also an option, which can successfully resect the tumor in a complete manner, reduce the difficulty of the operation, and prolong the patient\u0026rsquo;s survival period. This surgical approach does not require special medical equipment, and clinicians need to fully understand the anatomical structure, which makes it easy to promote its application.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eLocally recurrent rectal cancer (LRRC)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePositron emission tomography-computed tomography (PET- CT)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMagnetic resonance imaging\u0026nbsp;\u003c/em\u003e\u003cem\u003e(MRI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComputed Tomography\u003c/em\u003e\u003cem\u003e\u0026nbsp;(CT)\u003c/em\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAll claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher\u003cstrong\u003e.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants\u0026rsquo; legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors of the manuscript have read and agreed to its content and are accountable for all aspects of the accuracy and integrity of the manuscript in accordance with ICMJE criteria. That the article is original, has not already been published in a journal, and is not currently under consideration by another journal.\u003c/em\u003e \u003cem\u003eThe authors have agreed and signed an informed consent form with the patient in the case, and the patient gave informed consent.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by Grants Provided by Guizhou Provincial Science and Technology Agency (Qiankehe Jichu\u0026ndash;ZK2022\u0026ndash;No.580), and Zunyi Science and Technology Bureau (Zunshikehe\u0026ndash;HZ2022\u0026ndash;No.56).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLZ: Investigation, Writing \u0026ndash; original draft, Resources. \u0026nbsp;LH: Writing \u0026ndash; review \u0026amp; editing. XJ: Writing \u0026ndash; review \u0026amp; editing. MW: Writing \u0026ndash; review \u0026amp; editing. WZ: Writing \u0026ndash; review \u0026amp; editing. GW: Writing \u0026ndash; review \u0026amp; editing. \u0026nbsp;WY: Writing \u0026ndash; review \u0026amp; editing. TL: Writing \u0026ndash; review \u0026amp; editing. GW: Writing \u0026ndash; review \u0026amp; editing.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe thank our colleagues for their help. We acknowledge the patient\u0026rsquo;s contributions to the study.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"_com_1\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;Per journal guidelines, all manuscripts reporting studies involving human participants, human data or human tissue must include a statement on ethics approval and consent (even where the need for approval was waived). Within the statement, please include the name of the ethics committee that approved the study and the committee\u0026rsquo;s reference number, if appropriate. Studies involving animals must include a statement on ethics approval. If your manuscript does not report on or use any animal or human data or tissue, please write \u0026ldquo;Not applicable\u0026rdquo; in this section.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_2\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;Per journal guidelines, if your manuscript contains any individual person\u0026rsquo;s data in any form (including individual details, images or videos), consent for publication must be obtained from that person, or in the case of children, consent must be obtained from their parent or legal guardian. Please include a statement regarding consent for publication here. If your manuscript does not contain data from any individual person, please write \u0026ldquo;Not applicable\u0026rdquo; in this section.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_3\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;Per journal guidelines, all manuscripts must include an \u0026apos;Availability of data and materials\u0026apos; statement. Please include one here. If your manuscript does not contain any data, please write \u0026apos;Not applicable\u0026apos; here. For samples of data availability statements, please see the journal guidelines: https://wjso.biomedcentral.com/\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_4\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u003ca href=\"#_msoanchor_4\"\u003e\u003c/a\u003ePer journal guidelines, all financial and non-financial conflicts of interest must be declared in this section. Please use the authors\u0026rsquo; initials to refer to each author\u0026apos;s competing interests. If you do not have any competing interests, please write \u0026quot;The authors declare that they have no competing interests\u0026quot; in this section.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_5\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;Per journal guidelines, all sources of funding for the research presented in this manuscript should be declared here. The role of the funding body in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript should be declared. If there is no funding to declare, please write \u0026ldquo;Not applicable\u0026rdquo;.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_6\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u003ca href=\"#_msoanchor_6\"\u003e\u003c/a\u003ePer journal guidelines, the individual contributions of each author to the manuscript should be specified here. Please use the authors\u0026rsquo; initials to refer to each author\u0026apos;s contribution. For example, \u0026quot;FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.\u0026quot;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"_com_7\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;Per journal guidelines, please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials. If you do not have anyone to acknowledge, please write \u0026quot;Not applicable\u0026quot; in this section.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKeller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol. 2020;17:414-29.\u003c/li\u003e\n\u003cli\u003eZaborowski A, Stakelum A, Winter DC. Systematic review of outcomes after total neoadjuvant therapy for locally advanced rectal cancer. Br J Surg. 2019;106:979-87.\u003c/li\u003e\n\u003cli\u003eWestberg K, Palmer G, Hjern F, Johansson H, Holm T, Martling A. Management and prognosis of locally recurrent rectal cancer - a national population-based study. Eur J Surg Oncol. 2018;44:100-7.\u003c/li\u003e\n\u003cli\u003eLee DJ, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: how far have we come? World J Gastroenterol. 2017;23:4170-80.\u003c/li\u003e\n\u003cli\u003eFernandes MC, Gollub MJ, Brown G. The importance of MRI for rectal cancer evaluation. Surg Oncol. 2022;43:101739.\u003c/li\u003e\n\u003cli\u003eLu YY, Chen JH, Chien CR, Chen WT, Tsai SC, Lin WY, et al. Use of FDG-PET or PET/CT to detect recurrent colorectal cancer in patients with elevated CEA: a systematic review and meta-analysis. Int J Colorectal Dis. 2013;28:1039-47.\u003c/li\u003e\n\u003cli\u003eNational Health Commission of the People\u0026apos;s Republic of China. Chinese standards for diagnosis and treatment of colorectal cancer (2023 edition). Chin J Gastrointest Surg. 2023;22:667-98.\u003c/li\u003e\n\u003cli\u003eSelvaggi F, Fucini C, Pellino G, Sciaudone G, Maretto I, Mondi I, et al. Outcome and prognostic factors of local recurrent rectal cancer: a pooled analysis of 150 patients. Tech Coloproctol. 2015;19:135-44.\u003c/li\u003e\n\u003cli\u003eZhang JL, Wu T, Chen GW, Wang PY, Jiang Y, Tang JQ, et al. Analysis on risk factors of the degree of radical resection and prognosis of patients with locally recurrent rectal cancer. Zhonghua Wei Chang Wai Ke Za Zhi. 2020;23:472-9.\u003c/li\u003e\n\u003cli\u003eBeyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013;100:E1-33.\u003c/li\u003e\n\u003cli\u003eBeyond TME Collaborative. Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes. Br J Surg. 2013;100:1009-14.\u003c/li\u003e\n\u003cli\u003eOmarov N, Uymaz DS, Bugra D. Different uses of the breast implant to prevent empty pelvic complications following pelvic exenteration. BMJ Case Rep. 2022;15:e245630.\u003c/li\u003e\n\u003cli\u003eWang G, Wang C, Wang Y, Zhang G, Liu Y, Wang F, et al. Multiple surgical approaches and anatomy for the resection of presacral cysts. Chin J Anat Clin. 2023;8:419-22.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"local recurrence of rectal cancer, vagina, radical resection, longitudinal incisional approach via the sacral prone position","lastPublishedDoi":"10.21203/rs.3.rs-4291181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4291181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Locally recurrent rectal cancer (LRRC) refers to the lesions that appear in the pelvic cavity and perineum with the same pathological type as the primary tumor after radical operation of rectal cancer, excluding other distant metastases such as liver, lung, and bone. Radical surgical resection in such patients is a central element in improving quality of life and survival. In this paper, we report the case of a patient who was admitted to our hospital with a recurrence of ulcerated moderately differentiated carcinoma of the lower rectum with vaginal involvement after comprehensive treatment. After discussion by a multidisciplinary team, surgical treatment was selected to be performed through a longitudinal incision approach in the prone position of the sacrum, with complete resection of the tumor tissues, which improved the patient's quality of life and increased her survival rate.","manuscriptTitle":"Recurrence with isolated vaginal metastasis after comprehensive treatment of ulcerated moderately differentiated carcinoma of the lower rectum: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 13:17:00","doi":"10.21203/rs.3.rs-4291181/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5987b80a-322b-46b5-8e3b-4b866e9b62fc","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-29T13:17:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-29 13:17:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4291181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4291181","identity":"rs-4291181","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}