PMC10166831_01
Preoperative imaging data. (A) CT showed the blood supply of the tumor originating from the branches of the SMA (red arrow). (B) CT showed a soft tissue mass on the right side of the pelvis (red arrow); the wall of the middle and lower rectum was thickened, with mild enhancement (white arrow). (C, D) MRI showed a mass in the pelvis (red arrow); the rectal lesion appeared hyperintense on DWI (white arrow).
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The wall of the middle and lower rectum was thickened, and the lumen of the lesion was narrowed, with mild enhancement ( Figures 1A, B ). Apparent diffusion coefficient (ADC) imaging showed a low signal, and the size of the lesion was determined to be approximately 5.4 cm x 4.9 cm; the boundary was still clear (considering the possibility of metastasis) ( Figure 1C ). DWI (b800) showed a significantly hyperintense signal, with predominantly intraluminal growth of the lesion ( Figures 1C, D ).
Surgical procedure. (A) A small intestinal mass with a rich blood supply was adherent to the pelvic cavity(white arrow). (B, C) The adhesion between the small bowel tumor(white arrow) and the pelvic cavity was loosened. (D) A distinct depression was visible in the anterior wall of the rectum, which was the location of the rectal lesion (white arrow). (E, F) The roots of the interior mesenteric artery (IMA) were dissected under laparoscopy, and the central lymph nodes were cleared. (G) The rectum was excised with a 60-mm linear-stapler (one firing) 2 cm below the tumor. (H) End-to-end anastomosis of the rectal stump and sigmoid colon was performed.
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At a distance of 80 cm from the ileocecal valve, a small intestinal mass of approximately 6 cm in size was observed with an uneven epidermis and a rich blood supply, which was adherent to the pelvic cavity ( Figure 2A ). We loosened the adhesion between the small bowel tumor and the pelvic cavity ( Figures 2B, C ) and placed the tumor in the right paracolic sulcus. A distinct depression was visible in the anterior wall of the rectum, which was the location of the rectal lesion ( Figure 2D ). The roots of the interior mesenteric artery (IMA) were dissected under laparoscopy, and the central lymph nodes were cleared ( Figure 2E, F ). After freeing the rectum from the surrounding space and coping with the rectal mesentery, the rectum was excised with a 60-mm linear stapler (one firing) 2 cm below the tumor ( Figure 2G ) . Subsequently, the small bowel was placed into the abdominal cavity, the pneumoperitoneum was reestablished, and end-to-end anastomosis of the rectal stump and sigmoid colon was performed with a 29-mm circular stapler ( Figure 2H ).
Photomicrographs. (A) Moderately differentiated invasive adenocarcinoma (hematoxylin and eosin, x20 magnification). (B) Small intestinal tumor consisting of fasciculate spindle cells (hematoxylin and eosin, x40 magnification).
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Postoperative pathological examination of the rectum showed stage IIB (pT4aN0M0), moderately differentiated adenocarcinoma with no lymph node involvement (0/28) ( Figure 3A ). Postoperative pathological examination of the small bowel showed a spindle cell-type stromal tumor 6 cm x 5 cm x 3.5 cm in size ( Figure 3B ), with a mitotic count less than 5/5 mm2 and no tumor necrosis; the tumor was high risk, with a WHO prognostic grouping of 3a.
The latest imaging data. (A, B) CT showed no metastatic disease or local progression, and the anastomosis healed well (white arrow).
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No widespread metastasis or local progression was found in the latest follow-up ( Figure 4 ).