PMC6149866_01
Abdominal ultrasound showed a 2.9x2.6 cm2 hypoechoic solid tumor with abundant blood flow signal.
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A 2.9x2.6 cm2 hypoechoic solid tumor with abundant blood flow signal was observed behind the bladder via abdominal ultrasound (Figure 1).
Pelvic magnetic resonance imaging showed that a 3.1x2.6 cm2 nodule (blue arrows) had invaded the rectum.. Notes: (A) T1 weighted image with sagittal view; (B) T2 weighted image with sagittal view; (C) T1 weighted image with axial view; (D) T2 weighted image with axial view.
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T2weighted image/fat suppression signal and a low diffusion-weighed imaging signal (Figure 2).
Trocar placement and the size of the trocars.
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One 12-mm diameter port was placed in the right lower abdomen, one 5-mm port was placed in the right paraumbilicus, and a 5-mm port was placed in the left lower abdomen (Figure 3).
Transanal specimen extraction via laparoscopic rectectomy without an abdominal incision.. Notes: (A) The tumor was located at the right front wall of the middle rectum; (B) naked intestines at 3 cm from the distal margin of the tumor; (C) naked intestines at 3 cm from the proximal margin of the tumor; (D) the distal rectum was dissected circularly; (E) the transected bowel was pulled out via the anus; (F) the distal circular stapling device anvil was fixed extracorporeally; (G) the colon was then repositioned into the abdomen; (H) the rectal stump was closed; (I) an endtoend circular anastomosis was performed.
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The mass (with a diameter of 4 cm) was located at the right front wall of the middle rectum and had invaded the gut cavity (Figure 4A). Intestines were dissected at 3 cm from the distal margin of the tumor and 3 cm from the proximal margin of the tumor via harmonic scalpel (Figure 4B and C). After copious rectal stump irrigation by iodophor diluent, the distal rectum was dissected circularly 2 cm from the distal margin of the tumor by a harmonic scalpel and the broken ends were sterilized by iodophor gauze (Figure 4D). The transected bowel was pulled out in continuity via the anus using sponge forceps (Figure 4E). The distal circular stapling device anvil was fixed extracorporeally with a purse-string suture (Figure 4F). The colon was then repositioned into the abdomen through the rectal stump (Figure 4G). Next, the rectal stump was closed (Figure 4H), the proximal anvil of the circular stapling device in the rectum was opened, and a straight end-to-end circular anastomosis was performed (Figure 4I).
Macroscopic observation of rectal neoplasm.. Notes: (A) Rectal serous membrane. (B) Rectal mucosal membrane.
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Postoperative pathology revealed poorly differentiated adenocarcinoma measuring 5x3.5x2.2 cm3 invading from the rectal serosa into the submucosa (Figure 5A and B).
Microscopic observation and immunochemistry of rectal neoplasm.. Notes: (A) Microphotography shows poorly differentiated cells of adenocarcinoma arranged in nests, with vessel invasion (HematoxylinEosin Gx100); (B) the immunochemistry showed that cells were WT1(3+); (C) the immunochemistry showed that cells were PAX2(3+); (D) the immunochemistry showed that cells were CDX2(-).
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The tumor cells were arranged in nests, and vessel invasion was present (Figure 6A). The immunochemical staining (Figure 6B-D) was AE1/AE3(3+), CA125(3+), CK7(3+), P16(3+), WT1(3+), PAX2(3+), PAX8(1+), CK5&6(-), CR(-), MC(-), P63(-), CDX2(-), and CK20(-).