Fournier Gangrene in a patient receiving chemo–radiation for rectal cancer

Fournier Gangrene in a patient receiving chemo–radiation for rectal cancer We herein present a case of a 24-year-old patient with a cT4N+ rectal cancer who developed Fournier’s gangrene (FG) 1 week after the completion of preoperative chemoradiotherapy. The patient was promptly referred to the surgical department where she was treated with antibiotics and repeated surgical debridement. FG is a rare and life-threatening situation that needs to be managed aggressively with no delay. The clinical image above is unique and characteristic of this clinical entity. A 24-year-old woman was diagnosed with a locally advanced Clinical examination revealed a black soft tissue extending cT4N+M0 rectal adenocarcinoma, infiltrating the anus, sphincter, from the right buttock to the adjacent perineal and anal levator ani and posterior wall of vagina. The patient received pre- skin, raising the possibility of the diagnosis of Fournier’s operative external beam radiotherapy (IMRT technique) com- Gangrene [FG], (Fig. 1). The patient was referred immediately bined with oral capecitabine, at a dose of 1500 mg twice daily to the surgical department where she underwent repeated (825 mg/m was administered concurrently with radiotherapy extensive surgical debridement and received antibiotic treat- twice daily). Overall 50.5 Gy were administered in 25 fractions in ment. The post-surgical recovery was unremarkable and the 5 weeks. The Gross tumour volume including the primary patient was discharged 2 months later. Recently one year tumour and depicted locoregional disease received 5040 cGy and later, the patient is alive and a local recurrence has been the clinical target volume (the GTV plus a margin for sub-clinical diagnosed in the left para-rectal/anal region. The patient is disease spread) 4500 cGy. No major toxicity was noted during currently receiving re-irradiation with volumetric modulated treatment. arc therapy technique. At all instances, her disease was con- One week after the completion of radiochemotherapy, the sidered inoperable. patient presented with severe perineal pain, fever, weak- FG, in colorectal cancer patients receiving radiotherapy is an ness, disorientation and a deteriorated clinical status. extremely rare but life-threatening complication that has been Received: October 12, 2017. Revised: November 19, 2017. Accepted: December 13, 2017 © The Author(s) 2017. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx101/4911313 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Fournier Gangrene in a patient receiving chemo–radiation for rectal cancer 69 CONFLICT OF INTEREST STATEMENT None declared. FUNDING No sources of funding. ETHICAL APPROVAL Institutional Ethical Approval was given from B.O.C Oncology Center for publication. CONSENT The patient has given written consent for publication of the case. Figure 1: A black oedematous soft tissue extending from the right buttock to the adjacent perineal - anal skin is depicted. REFERENCES 1. Nabha KS, Badwan K, Kerfoot BP. Fournier’s gangrene as a described in the literature only twice [1, 2]. The mortality of FG complication of steroid enema use for treatment of radiation is extremely high thus early diagnosis and aggressive manage- proctitis. Urology 2004;63:587–8. ment are crucial for patient’s outcome [3]. A study with the lar- 2. Lederman E, Mathieu D, Lescut D, Wattel F, Paris JC. Perineal gest patient series in the literature, conducted by Yilmazlar anaerobic necrotizing cellulite after preoperative radiother- et al. [4], showed that FG is associated with a significant risk of apy for rectal cancer]. [Article in French]. Gastroenterol Clin mortality, that reaches 20,8%, if not treated with aggressive surgi- Biol 1998;22:360–1. cal procedures and antibiotics. This case was interesting since FG 3. Bruketa T, Majeronic M, Augustin G. Rectal cancer and occurred within the irradiated area. Prompt clinical diagnosis Fournier’s Gangrene—current knowledge and therapeutic and surgical management were crucial for patient’s favourable options. World J Gastroenterol 2015;21:9002–20. outcome. The clinical picture presented above is unique and 4. Yilmazlar T, Isik O, Ozturk E, Ozer A, Gulcu B, Ercan I. will help fellow clinicians in the diagnosis of this severe Fournier’s Gangrene: a review of 120 patients and predictors condition. of mortality. Ulus Travma Acil Cerrahi Derg 2014;20:333–7. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx101/4911313 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Oxford Medical Case Reports Oxford University Press

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Oxford University Press
Copyright
© The Author(s) 2017. Published by Oxford University Press.
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2053-8855
D.O.I.
10.1093/omcr/omx101
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Abstract

We herein present a case of a 24-year-old patient with a cT4N+ rectal cancer who developed Fournier’s gangrene (FG) 1 week after the completion of preoperative chemoradiotherapy. The patient was promptly referred to the surgical department where she was treated with antibiotics and repeated surgical debridement. FG is a rare and life-threatening situation that needs to be managed aggressively with no delay. The clinical image above is unique and characteristic of this clinical entity. A 24-year-old woman was diagnosed with a locally advanced Clinical examination revealed a black soft tissue extending cT4N+M0 rectal adenocarcinoma, infiltrating the anus, sphincter, from the right buttock to the adjacent perineal and anal levator ani and posterior wall of vagina. The patient received pre- skin, raising the possibility of the diagnosis of Fournier’s operative external beam radiotherapy (IMRT technique) com- Gangrene [FG], (Fig. 1). The patient was referred immediately bined with oral capecitabine, at a dose of 1500 mg twice daily to the surgical department where she underwent repeated (825 mg/m was administered concurrently with radiotherapy extensive surgical debridement and received antibiotic treat- twice daily). Overall 50.5 Gy were administered in 25 fractions in ment. The post-surgical recovery was unremarkable and the 5 weeks. The Gross tumour volume including the primary patient was discharged 2 months later. Recently one year tumour and depicted locoregional disease received 5040 cGy and later, the patient is alive and a local recurrence has been the clinical target volume (the GTV plus a margin for sub-clinical diagnosed in the left para-rectal/anal region. The patient is disease spread) 4500 cGy. No major toxicity was noted during currently receiving re-irradiation with volumetric modulated treatment. arc therapy technique. At all instances, her disease was con- One week after the completion of radiochemotherapy, the sidered inoperable. patient presented with severe perineal pain, fever, weak- FG, in colorectal cancer patients receiving radiotherapy is an ness, disorientation and a deteriorated clinical status. extremely rare but life-threatening complication that has been Received: October 12, 2017. Revised: November 19, 2017. Accepted: December 13, 2017 © The Author(s) 2017. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx101/4911313 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Fournier Gangrene in a patient receiving chemo–radiation for rectal cancer 69 CONFLICT OF INTEREST STATEMENT None declared. FUNDING No sources of funding. ETHICAL APPROVAL Institutional Ethical Approval was given from B.O.C Oncology Center for publication. CONSENT The patient has given written consent for publication of the case. Figure 1: A black oedematous soft tissue extending from the right buttock to the adjacent perineal - anal skin is depicted. REFERENCES 1. Nabha KS, Badwan K, Kerfoot BP. Fournier’s gangrene as a described in the literature only twice [1, 2]. The mortality of FG complication of steroid enema use for treatment of radiation is extremely high thus early diagnosis and aggressive manage- proctitis. Urology 2004;63:587–8. ment are crucial for patient’s outcome [3]. A study with the lar- 2. Lederman E, Mathieu D, Lescut D, Wattel F, Paris JC. Perineal gest patient series in the literature, conducted by Yilmazlar anaerobic necrotizing cellulite after preoperative radiother- et al. [4], showed that FG is associated with a significant risk of apy for rectal cancer]. [Article in French]. Gastroenterol Clin mortality, that reaches 20,8%, if not treated with aggressive surgi- Biol 1998;22:360–1. cal procedures and antibiotics. This case was interesting since FG 3. Bruketa T, Majeronic M, Augustin G. Rectal cancer and occurred within the irradiated area. Prompt clinical diagnosis Fournier’s Gangrene—current knowledge and therapeutic and surgical management were crucial for patient’s favourable options. World J Gastroenterol 2015;21:9002–20. outcome. The clinical picture presented above is unique and 4. Yilmazlar T, Isik O, Ozturk E, Ozer A, Gulcu B, Ercan I. will help fellow clinicians in the diagnosis of this severe Fournier’s Gangrene: a review of 120 patients and predictors condition. of mortality. Ulus Travma Acil Cerrahi Derg 2014;20:333–7. Downloaded from https://academic.oup.com/omcr/article-abstract/2018/2/omx101/4911313 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Oxford Medical Case ReportsOxford University Press

Published: Feb 1, 2018

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