Adenocarcinoma mucinoso de colon T4b con fístula colosigmoidea y afectación ureteral

Adenocarcinoma mucinoso de colon T4b con fístula colosigmoidea y afectación ureteral: manejo quirúrgico y revisión de la evidencia

Mucinous T4b colon adenocarcinoma with colosigmoid fistula and ureteral involvement: surgical management and review of the evidence

Óscar García Villar*, Irene Fernández Sevillano*, Alfredo Vivas López*, Eduardo Rubio González*, Eduardo Ferrero Herrero*

* Servicio Cirugía General, Aparato Digestivo y Trasplante de Órganos Abdominales.
     Hospital Universitario 12 de Octubre. Madrid (España).

DOI: https://doi.org/10.14679/5197

Resumen:

Introducción: El adenocarcinoma mucinoso de colon con estadio T4b representa un subgrupo de especial complejidad quirúrgica y oncológica. La invasión de estructuras adyacentes, la formación de fístulas y la afectación del uréter condicionan la planificación y los resultados de la cirugía. Su presentación inicial como proceso inflamatorio supone un reto diagnóstico adicional que puede retrasar el tratamiento definitivo.
Caso clínico: Varón de 59 años con antecedentes de episodio previo diagnosticado como posible apendicitis/diverticulitis aguda evolucionada tratada de forma conservadora. Reestudio en nuestro centro donde se diagnosticó un adenocarcinoma mucinoso de ciego con fístula al sigma (T4bN0M0), confirmado mediante colonoscopia, biopsia y TC. Se realizó hemicolectomía derecha y sigmoidectomía laparoscópicas en un mismo tiempo quirúrgico. Intraoperatoriamente se confirma afectación del uréter derecho y del peritoneo parietal. La anatomía patológica verifica un carcinoma colorrectal estadio pT4bN0, márgenes radiales afectos y ausencia de metástasis en 39 ganglios linfáticos analizados. El postoperatorio cursó favorablemente.
Revisión: La evidencia actual sobre el tratamiento del cáncer de colon T4b apoya la resección en bloque como pilar terapéutico fundamental. La resección R0 es el principal factor pronóstico independiente. El abordaje laparoscópico en manos expertas ha demostrado ser seguro en casos seleccionados. El margen radial afecto condiciona la indicación de tratamiento adyuvante intensificado.
Conclusión: El adenocarcinoma mucinoso de colon T4b con fístula y afectación ureteral requiere una planificación quirúrgica meticulosa y un abordaje multidisciplinar. La hemicolectomía derecha con sigmoidectomía laparoscópica sincrónica es factible y segura en centros con experiencia. El margen radial afecto y el subtipo mucinoso son factores que condicionan el pronóstico y la estrategia adyuvante.
Palabras Clave: Cáncer de colon T4b; Adenocarcinoma mucinoso; Fístula colosigmoidea; Hemicolectomía derecha; Sigmoidectomía; Afectación ureteral; Cirugía laparoscópica.

Abstract:

Introduction: Mucinous T4b colon adenocarcinoma represents a subgroup of particular surgical and oncological complexity. Invasion of adjacent structures, fistula formation and ureteral involvement determine the surgical planning and outcomes. Initial presentation as an inflammatory process poses an additional diagnostic challenge that may delay definitive treatment.
Case report: A 59-year-old male with a previous episode diagnosed as possible acute appendicitis/diverticulitis managed conservatively. Restaging at our centre documented mucinous adenocarcinoma of the caecum with fistula to the sigmoid colon (T4bN0M0), confirmed by colonoscopy, biopsy and CT scan. Laparoscopic right hemicolectomy and sigmoidectomy were performed simultaneously. Intraoperative findings confirmed involvement of the right ureter and parietal peritoneum. Pathological examination confirmed stage pT4bN0, positive radial margins and no metastases in 39 lymph nodes. The postoperative course was uneventful.
Review: Current evidence on the treatment of T4b colon cancer supports en bloc resection as the fundamental therapeutic cornerstone. R0 resection is the main independent prognostic factor. Laparoscopic approach in experienced hands has proven safe in selected cases. Positive radial margin determines the indication for intensified adjuvant therapy.
Conclusion: T4b mucinous colon adenocarcinoma with fistula and ureteral involvement requires meticulous surgical planning and a multidisciplinary approach. Synchronous laparoscopic right hemicolectomy and sigmoidectomy is feasible and safe in experienced centres. Positive radial margin and mucinous subtype are factors conditioning prognosis and adjuvant strategy.

Key words: T4b colon cancer; Mucinous adenocarcinoma; Colosigmoid fistula; Right hemicolectomy; Sigmoidectomy; Ureteral involvement; Laparoscopic surgery.

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