PMC10225707_01
Preoperative CT and postoperative pathology for first radical rectal cancer: CT scan showed obvious thickening of the intestinal wall at the junction of the rectum and sigmoid colon, and soft tissue mass shadow with uneven density (A). CT enhanced scan showed uneven enhancement of soft tissue masses at the rectosigmoid junction and local intestinal cavity was obviously narrow (B). Part of intestinal duct (rectal mass), 18 cm long, 6-8 cm in circumference, 6cm away from the cut edge at one end, and a cauliflower-like mass 8 cm from the cut edge at the other end, 7cm x 5cm x 2 cm in size (C). The cancer tissue of rectal mass was arranged in irregular glandular tubular and sieve shape, infiltrating the whole intestinal wall and breaking through the serous layer. The cancer cells were obviously heteromorphic, with large nuclei, deep staining and frequent mitotic images (D).
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The patient's final diagnosis was a moderately differentiated adenocarcinoma of the rectum (pT4bN2aM1b stage IV). ( Figure 1 ) Immunohistochemistry showed CK (+), CDX-2 (+) and approximately 30% P53 in cancer cells.
Pre-pelvic exenteration colonoscopy, CT, post-operative pathology and reconstruction: CT scan showed a mass-like slightly hypodense shadow next to the right side of the rectal stump. The lesion was poorly demarcated from the right vaginal wall and presacral soft tissue and invaded the surrounding tethered fascia and right levator ani muscle. The rectal cavity was compressed and deformed(A-C). The blind end was observed at 8cm away from the anus through the natural anus, and the intestinal mucosa was covered with white contents(D). The cancer tissue invaded the entire bowel wall, the entire vagina, involving the surrounding striated muscle tissue and adipose tissue, the local prolusion of the bladder mucosa, and localized necrosis of the serous layer and the muscular layer(E). After pelvic exenteration, the patient underwent free myocutaneous flap graft (F).
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Due to the large size of the surgical wound which was difficult to heal on its own, we performed a free myocutaneous flap graft and skin and subcutaneous necrotic tissue debridement on the lower back in September 2022. ( Figures 2 ,  3 ).
The patient had undergone seven surgeries (radical rectal cancer surgery and right ovariectomy in October 2015, left ovariectomy in August 2017, partial rectal resection in March 2021, radiofrequency ablation and particle implantation in July 2021, pelvic exenteration in July 2022, and two reconstructive surgeries in September 2022). During treatment, the patient had been taking chemotherapy drugs, including first-line chemotherapy drugs: XELOX (oxaliplatin and capecitabine), second-line chemotherapy drugs: FOLFIRI (irinotecan, leucovorin, and fluorouracil) and bevacizumab, and third-line therapy drugs: regorafenib.
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Due to the large size of the surgical wound which was difficult to heal on its own, we performed a free myocutaneous flap graft and skin and subcutaneous necrotic tissue debridement on the lower back in September 2022. ( Figures 2 ,  3 ).