BackgroundIn order to overcome the shortcomings of laparoscopic intersphincteric resection (Lap ISR), an alternative method of delivering intraoperative radiotherapy by Intrabeam X-rays radiotherapy system (XRS) is proposed in this paper. Intrabeam XRS is a device that uses low-energy X-rays source generated by a mobile controller unit, which is featured in accurate irradiation, reduced complications, and less exposure. The purpose of this study is to discuss the feasibility of Lap ISR with intra-operative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer in Asian woman. This novel proposed method will greatly increase the anus preserving probability and improved the quality of life.MethodsA 53-year-old woman diagnosed with rectal adenocarcinoma had a strong desire to preserve the anal function and presented at the Jilin University Second Hospital, Jilin, China. The tumor’s size was 4 cm × 3 cm. It was located 2 cm from the anus merge and invaded the levator ani muscle. Preoperative clinical staging was T4N1M0 and could be reached R0 resection. After the consent form was signed by the patient, Lap ISR combined with the applicator put through the anus (natural orifice) to the tumor bed was performed and prophylactic ileostomy synchronized the anastomosis. Patient only received 1-cycle chemotherapy regimen of oxaliplatin with capecitabine postoperatively due to personal reasons. Pre- or postoperative radiotherapy was not given.ResultsAfter clinical follow-up, until now, there is not any sign of local recurrence. Anus function and short-term complications are acceptable. The short-term effect is satisfying and we look forward to further assess the long-term effect.ConclusionLaparoscopic intersphincteric resection with IORT using low-energy X-rays for the patients with late-stage ultra-low rectal cancer could provide an opportunity of preserving the anus function, and it is feasible for the selected patients.Trial registrationRetrospectively registered; Trial registration: NCT03393234; Registered time: 05 January 2017.

Background: Even with the augmentative application of anal-preservation surgery in low rectal cancer, the role and indications of laparoscopic intersphincteric resection (Lap ISR) are still under debate, especially for T3 or nodepositive (T3N0M0, T1-3N+M0) cancer, mainly due to the oncological safety and functional outcomes. INTRABEAM (Carl Zeiss, Germany) intraoperative radiotherapy (IORT) using low-energy X-rays features in accurate irradiation, less exposure, and reduced complications. Taking advantages of Lap ISR and INTRABEAM IORT, this innovative approach aims to increase the probability of the anal preservation with acceptable postoperative outcomes. Materials and methods: From December 2015 to August 2019, we retrospectively analyzed the short-term outcomes of 12 patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1-3N+M0) primary locally advanced low rectal cancer. They all had received Lap ISR and INTRABEAM IORT with a dose of 16-18 Gy applied by an applicator through the anus (natural orifice). Then, with no pre-or postoperative radiotherapy given, the patients were suggested to receive 6-8 cycles of the XELOX chemotherapy regimen (oxaliplatin, 130 mg/m 2 and capecitabine, 1000 mg/m 2). Results: All patients achieved R0 resection. The median radiation time was 27 min and 15 s, and the mean radiative dose was 17.3 Gy (range 16-18 Gy). The median follow-up time was 18.5 months (range 3-45 months). Two patients experienced local recurrence. Two male patients experienced anastomotic stenosis. Furthermore, one of them experienced perianal abscess and the other one experienced pulmonary metastasis after refusing to receive chemotherapy. One female patient with internal anal sphincter invasion experienced distant metastases to the liver and gluteus maximus muscle 35 months after IORT. No acute radiation injuries or symptoms were observed. Although they experienced a reduction in anal function, every patient was satisfied with the postoperative outcomes.

Rationale: Adenocarcinoma coexists with adjacent microscopic gastrointestinal stromal tumor (micro-GIST) is rare, especially in the rectum, where the gastrointestinal stromal tumors (GISTs) have the lower incidence rate. It is easy to ignore the concurrent micro-GIST due to the untypical symptoms. Patient concerns: A 77-year-old male patient suffered from lower abdominal pain for 20 days and presented with per rectal bleeding for 10 days. He had the medical history of hypertension and diabetes for more than 25 years. Diagnoses: Endoscopy revealed that the patient had rectum adenocarcinoma and multiple rectum polyps. Besides, the gastrointestinal stromal tumor was diagnosed by the pathologist. Interventions: The patient underwent surgery of laparoscopic rectum resection and prophylactic ileostomy and took 6 courses of Capecitabine tablets orally. Outcomes: One year after surgery, the patient had no local relapse by the CT scan. However, not long after the CT examination, he died of cardiovascular disease. Lessons: Although micro-GIST may be noninvasive and asymptomatic, it may have the potential for transforming to malignancies. More attention should be paid to the patients diagnosed with gastrointestinal malignancy coexisting with micro-GIST.

Rationale: Situs invsersus totalis (SIT) is a rare anomaly featured by complete inversion of abdominal and thoracic organs. Adrenal metastasis is often encountered as part of advanced systemic dissemination, which is usually unresectable. Few published cases reported the adrenal metastasis from gastric cancer with SIT and the treatment of gastrectomy combined with adrenalectomy, especially with intraoperative radiotherapy (IORT). Patient concerns: A 61-year-old SIT man found a mass on the right clavicle and the biopsy revealed a metastatic cancer. Around 14 years ago, he had a rectal cancer resection surgery and no sign of occurrence. Five months later, the patient had a pain in his right low abdomen and abdominal CT found a right adrenal mass. Diagnoses: Gastroscopy and the pathology revealed the gastric antrum cancer invading the duodenal bulb. Abdominal enhanced CT suspected the adrenal mass as a hematoma, but positron emission tomography computed tomography suspected it as the metastases of gastric cancer which is consistent with the pathology results. Finally, the SIT patient was diagnosed with primary gastric cancer invading duodenal bulb with solitary right adrenal metastasis. Interventions: The patient was treated with curative distal gastrectomy and Billroth-II anastomosis with D2 lymphadenectomy. A total 18 Gy intraoperative radiotherapy (IORT) using low energy x-rays by Intrabeam were given after resection. Outcomes: The patient had liver metastasis in the seventh month after surgery but there is no sign of local recurrence until now. Lessons: Gastric cancer with adrenal metastasis, especially with SIT is rare and intractable. The result suggested that active surgical treatment for resectable gastric cancer and solitary adrenal metastatic tumor, especially in combination with IORT may be an option in controlling local relapse and prolonging survival in selected patients.

Background: Colon cancer is a common malignant disease of the gastrointestinal tract and usually occurs at the junction of the rectum and sigmoid colon. Lymphatic and hematogenous metastases occur frequently in colon cancer and the most common metastatic sites include the regional liver, lung, peritoneum, bone, and lymph nodes. As a manifestation of advanced tumor spread and metastasis, soft tissue metastasis, especially skeletal muscle metastasis ossification caused by colon cancer, is rare, accounting for less than 1% of metastases.Case presentation: In this study, we report a rare case of a 43-year-old male patient who developed an ossifying skeletal muscle metastasis of the right proximal thigh with severe pain at 5 months after colon cancer was diagnosed, who subsequently from the developed metastasis. The patient was admitted to the hospital because of pain caused by a local mass on his right thigh. Positron emission tomography-computed tomography showed multiple lymphadenopathy metastases around the abdominal aorta without lung or liver metastases. Color ultrasound revealed a mass located in the skeletal muscle and the results of histological biopsy revealed a poorly differentiated adenocarcinoma suspected to be distant metastases from colon cancer and immunohistochemistry showed small woven bone components that were considered to be ossified. Conclusion: Although ossifying skeletal muscle metastases is rare, its potential malignancy is high. With advances in examinations and treatment modality, Positron emission tomography-computed tomography, collagen gel droplet culture drug-sensitivity test and genetic tests are recommended to optimize comprehensive and individual treatment modality to prolong patient survival.