CURATIVE LAPAROSCOPIC RECTAL CANCER RESECTION IN A PATIENT WITH ASYMPTOMATIC METASTATIC DISEASE IN THE SMALL BOWEL MESENTERY FROM PROSTATE CANCER

123| Page CURATIVE LAPAROSCOPIC RECTAL CANCER RESECTION IN A PATIENT WITH ASYMPTOMATIC METASTATIC DISEASE IN THE SMALL BOWEL MESENTERY FROM PROSTATE CANCER Thomas Athisayaraj, Boby Sebastian, Akshay Akulwar, Emmanuel Lorejo , Justin Alberts 1,2,3,4,5 West Suffolk Hospital, Hardwick Ln, Bury St Edmunds, IP33 2QZ Article Info: Received 08 April 2020; Accepted 25 May 2020 DOI: https://doi.org/10.32553/ijmbs.v4i5.1163 Corresponding author: Thomas W Athisayaraj Conflict of interest: No conflict of interest. Abstract


Introduction
We present an interesting case of prostate cancer presenting with multiple small nodular deposits in the small bowel mesentery A 75 yr old man presented to our colorectal fast track clinic with bleeding PR. There was no palpable rectal pathology in digital rectal examination. We arranged a colonoscopy for him.
The colonoscopy showed upper rectal cancer. The staging MRI revealed T3 disease and there was no evidence of metastatic disease in the CT chest abdomen and pelvis.
He had a background of prostate cancer. He had open radical prostatectomy in 2004.The histology was adenocarcinoma of the prostate Gleason 4+3=7 PSA 9.2 pT3 (positive apical margin) with positive excision margins. He had radical pelvic radiotherapy 55Gy in 20 cycles to the prostatic bed finished in August 2011. He is on Zoladex/Decapeptyl started in July 2018 and Enzalutamide 160mg once a day started in October 2018 Even Though there was no obvious evidence of metastatic disease in the follow up there was a sustained unexplained rise in PSA levels. Currently he is also on Tamoxifen.
The above treatment is for presumed micrometastatic disease.
This gentleman is very well with good performance status. He also had surgery for an acoustic neuroma in 2007 which has left him deaf in his left ear.
There is also a h/o complicated cataract surgery which resulted in loss of sight in the left eye.
Following our discussion in our colorectal MDT we decided to proceed straight to surgery.
We did laparoscopic low anterior resection with PME (Partial meso rectal excision) for his rectal cancer. The operation went on smoothly. The left sided mobilisation was bit difficult due to previous retroperitoneal lymphadenectomy along with radical prostatectomy.
After finishing the anastomosis we noticed multiple whitish nodular deposits in the small bowel mesentery.
There were no deposits in the peritoneum or omentum. We took biopsies and completed a defunctioning loop ileostomy.
The patient recovered well and went home on day 5 without any problems.
The biopsies from small bowel mesentery showed metastatic prostate cancer.

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This type of metastasis is extremely rare 16 years after the initial surgery and this is the reason for presenting this case.
There are reported cases of prostate cancer metastasing to small bowel leading onto obstruction. There is a reported case of prostate cancer mets presenting as RIF mass. The patient underwent right hemicolectomy for a presumed caecal cancer but the histology confirmed metastatic deposit from caecal cancer 3 Virendra Bhandhari has reported a case of metastatic deposit from prostate cancer presenting as gastric nodule noted in endoscopy. 4 The loco regional metastasis to the rectum and sigmoid from prostate cancer is about 1 to 12 %. 5 .
It will be interesting to see the progress of these tiny metastatic deposits in the small bowel mesentery

Conclusion
Metastatic deposits from prostate cancer can occur in the bowel,stomach,duodenum and the presentation is variable ranging from asymptomatic tiny deposits to huge deposits resulting in local symptoms. The presence of these tiny deposits should not be a deterring factor for treatment for another primary cancer.