anorectal melanoma is associated with an extremely poor prognosis regardless of the aggressiveness of surgical therapy ; it is commonly incurable at presentation , with many patients developing systemic metastasis within a year after diagnosis .
however , reports have noted that long - term survival was seen only in patients who underwent an abdominoperineal resection instead of wide local excision .
it is estimated that only 0.1 - 0.5% of all rectal tumors are leiomyosarcomas ; only 136 cases of rectal leiomyosarcoma had been recorded in a 1986 literature review . local excision carries an approximately 80 - 85% chance of recurrence . since 80% of these tumors are in the distal rectum , abdominoperineal excision has been the most frequently performed operation .
the five - year survival rate in most series seems to be 20 - 25% after radical surgery .
kaposi 's sarcoma is often asymptomatic and as such usually requires no treatment , but surgery is sometimes indicated to control bleeding or obstructive symptoms .
proponents of laparoscopic abdominoperineal resection cite arguments in favor , that the extended lymph node dissection , the mobilization of the rectum and the mesorectum and stoma creation can be laparoscopically performed ; furthermore , the transperineal tumor removal is affected .
nonetheless , local wound recurrence of tumor cells in the port sites of patients who have undergone curative laparoscopic procedures for cancer are of major concern . due to relative prevalence rates , other series
therefore , the aim of this study was to assess the results of laparoscopic abdominoperineal resection for treatment of non - carcinomatous malignancies .
all five patients were referred to our department for treatment of biopsy - proven neoplasms . in four cases
preoperative staging included computerized axial tomography ( cat ) scan and anorectal ultrasound and in all cases failed to identify distant or nodal disease , respectively .
all patients underwent conventional preoperative mechanical bowel preparation and received routine oral and parenteral antibiotic prophylaxis .
operative steps include : 1 ) mobilization of the left colon ; 2 ) division of the inferior mesenteric vessels ; 3 ) division of the mesentery ; 4 ) total mesorectal excision ; 5 ) division of bowel at the sigmoid - descending junction ; 6 ) perineal dissection in the standard fashion with specimen removal ; and 7 ) end colostomy creation . the operative time ,
intraoperative findings , transfusion requirement , intra- and postoperative complications , length of hospitalization , and outcomes of surgery were recorded for each patient .
a 75-year - old female patient presented to another surgeon with a primary tumor located 5 cm cephalad to the dentate line , on the posterior lateral aspect of the rectum .
histopathologic evaluation revealed an invasive malignant melanoma with vascular involvement ; high mitotic activity ( mean 6 mitoses per 107 high - power field [ hpf ] ) ; and a positive immunocytochemical profile of 100s - hmb 45/ 50 .
chest , abdominal and pelvic ct scans failed to reveal any local or distant metastasis . the melanoma was transanally removed .
six months after the local excision the patient presented with a gelatinous 4 cm diameter mass , localized on the left postero - lateral aspect of the dentate line , extending to the anorectal ring .
a pelvic and abdominal ct scan revealed a dense 2 cm ovoid mass on the left lateral wall of rectum , caudal to the levator ani , involving the puborectalis muscle .
although the patient had enlarged lymph nodes in the left ischiorectal fossa at the level of the levator ani , there were no distant metastases noted . at that time
the patient was referred to our department for evaluation of severe pain and rectal bleeding and underwent a laparoscopic abdominoperineal resection .
pathologic assessment showed metastatic , multicentric melanoma of the rectum , involving 8 of 9 lymph nodes .
four months after abdominoperineal resection , the ct scan found the liver extensively involved with metastatic lesions without port - site or local metastasis .
an 87-year - old male patient presented to another surgeon with a malignant melanoma infiltrating the external anal sphincter and puborectalis muscle . a wide local excision of the lesion was performed 3 cm cephalad to the dentate line . the patient was followed up for 18 months , during which time no distant or local metastases were revealed .
eighteen months later he was referred to our department with a deeply infiltrative 3 cm diameter anteriorly bound tumor at the level of the dentate line , involving the anterior rectal wall .
after abdominoperineal resection , the pathologist reported a tumor free distal margin of 0.8 cm , and 3 of the 7 pericolic harvested lymph nodes had metastatic foci .
postoperatively he developed a common bile duct obstruction due to stone impaction at the ampulla of vater , which was successfully removed by endoscopic retrograde cholangiopancreaticography .
the patient had uneventful recovery and two months after surgery had no evidence of any distal , local or port - site recurrence . a 69-year - old patient presented to another surgeon with a broad - based polypoid lesion of 1.5 cm diameter in the anal canal removed by endoscopic snare .
histologic studies showed a poorly differentiated primary tumor , with high mitotic activity which infiltrated the rectal wall ; immunohistochemical profile was positive for s100-hmb 45/50 .
the patient was followed up for two months , after which a biopsy revealed a local recurrence of malignant melanoma at the anterior dentate line .
the patient was referred to our department for curative resection of an early recurrence . rectal ultrasonography and
anoscopic evaluation revealed a 3 mm diameter anteriorly based lesion at the dentate line . because preoperative ct did not reveal any distant metastasis , the patient underwent laparoscopy with a view towards abdominoperineal resection .
unfortunately , two 4 cm diameter right - sided hepatic metastasis were identified and confirmed by percutaneous fine needle biopsy .
she died secondary to liver metastasis but without any port - site recurrence 46 days after surgery . a 68-year - old female patient who was receiving immunosuppressive agents for rheumatoid arthritis
was referred to our department for a primary tumor presenting as a firm mass in the left wall of the anal canal .
a graytan soft tissue weighing 42 grams within a diameter of 5.5  3.6  3.5 cm was removed by wide local excision , and histologic evaluation confirmed the diagnosis of leiomyosarcoma .
the patient underwent laparoscopic abdominoperineal resection after which the pathologist described the lesion as a lymphosarcoma .
two years later , the patient presented with a 2 cm diameter left obturator mass , with bilobar hepatic and bilateral pulmonary nodules .
however , neither ct scan nor magnetic resonance imaging revealed any port - site recurrences .
a 34-year - old white male patient presented to another surgeon with an advanced hiv infection . during his course , the patient had experienced both cutaneous and gastrointestinal kaposi 's sarcoma , cytomegalovirus gastritis , cryptosporidium , peripheral neuropathy , wasting , neutropenia and anemia .
office evaluation revealed two 4 cm diameter kaposi 's lesions in the rectum , one 5 cm and one 8 cm cephalad to the dentate line .
the patient was treated by chemotherapy and radiotherapy . however , one month later , he presented with obstructive symptoms , increased bleeding , and severe pain
. proctoscopy revealed near - occlusion of the lumen due to the two rectal lesions .
accordingly , it was elected to proceed with a laparoscopic loop ileostomy after which he was discharged home on postoperative day five in stable condition .
the patient died five months after the procedure due to systemic cytomegalovirus infection and seizures .
a 75-year - old female patient presented to another surgeon with a primary tumor located 5 cm cephalad to the dentate line , on the posterior lateral aspect of the rectum .
histopathologic evaluation revealed an invasive malignant melanoma with vascular involvement ; high mitotic activity ( mean 6 mitoses per 107 high - power field [ hpf ] ) ; and a positive immunocytochemical profile of 100s - hmb 45/ 50 .
chest , abdominal and pelvic ct scans failed to reveal any local or distant metastasis . the melanoma was transanally removed .
six months after the local excision the patient presented with a gelatinous 4 cm diameter mass , localized on the left postero - lateral aspect of the dentate line , extending to the anorectal ring .
a pelvic and abdominal ct scan revealed a dense 2 cm ovoid mass on the left lateral wall of rectum , caudal to the levator ani , involving the puborectalis muscle .
although the patient had enlarged lymph nodes in the left ischiorectal fossa at the level of the levator ani , there were no distant metastases noted . at that time
the patient was referred to our department for evaluation of severe pain and rectal bleeding and underwent a laparoscopic abdominoperineal resection .
pathologic assessment showed metastatic , multicentric melanoma of the rectum , involving 8 of 9 lymph nodes .
four months after abdominoperineal resection , the ct scan found the liver extensively involved with metastatic lesions without port - site or local metastasis .
an 87-year - old male patient presented to another surgeon with a malignant melanoma infiltrating the external anal sphincter and puborectalis muscle .
a wide local excision of the lesion was performed 3 cm cephalad to the dentate line .
the patient was followed up for 18 months , during which time no distant or local metastases were revealed .
eighteen months later he was referred to our department with a deeply infiltrative 3 cm diameter anteriorly bound tumor at the level of the dentate line , involving the anterior rectal wall .
after abdominoperineal resection , the pathologist reported a tumor free distal margin of 0.8 cm , and 3 of the 7 pericolic harvested lymph nodes had metastatic foci .
postoperatively he developed a common bile duct obstruction due to stone impaction at the ampulla of vater , which was successfully removed by endoscopic retrograde cholangiopancreaticography .
the patient had uneventful recovery and two months after surgery had no evidence of any distal , local or port - site recurrence .
a 69-year - old patient presented to another surgeon with a broad - based polypoid lesion of 1.5 cm diameter in the anal canal removed by endoscopic snare .
histologic studies showed a poorly differentiated primary tumor , with high mitotic activity which infiltrated the rectal wall ; immunohistochemical profile was positive for s100-hmb 45/50 .
the patient was followed up for two months , after which a biopsy revealed a local recurrence of malignant melanoma at the anterior dentate line .
the patient was referred to our department for curative resection of an early recurrence . rectal ultrasonography and anoscopic evaluation revealed a 3 mm diameter anteriorly based lesion at the dentate line . because preoperative ct did not reveal any distant metastasis , the patient underwent laparoscopy with a view towards abdominoperineal resection .
unfortunately , two 4 cm diameter right - sided hepatic metastasis were identified and confirmed by percutaneous fine needle biopsy .
she died secondary to liver metastasis but without any port - site recurrence 46 days after surgery .
a 68-year - old female patient who was receiving immunosuppressive agents for rheumatoid arthritis was referred to our department for a primary tumor presenting as a firm mass in the left wall of the anal canal .
a graytan soft tissue weighing 42 grams within a diameter of 5.5  3.6  3.5 cm was removed by wide local excision , and histologic evaluation confirmed the diagnosis of leiomyosarcoma .
the patient underwent laparoscopic abdominoperineal resection after which the pathologist described the lesion as a lymphosarcoma .
two years later , the patient presented with a 2 cm diameter left obturator mass , with bilobar hepatic and bilateral pulmonary nodules
. however , neither ct scan nor magnetic resonance imaging revealed any port - site recurrences .
a 34-year - old white male patient presented to another surgeon with an advanced hiv infection . during his course , the patient had experienced both cutaneous and gastrointestinal kaposi 's sarcoma , cytomegalovirus gastritis , cryptosporidium , peripheral neuropathy , wasting , neutropenia and anemia .
office evaluation revealed two 4 cm diameter kaposi 's lesions in the rectum , one 5 cm and one 8 cm cephalad to the dentate line .
the patient was treated by chemotherapy and radiotherapy . however , one month later , he presented with obstructive symptoms , increased bleeding , and severe pain .
accordingly , it was elected to proceed with a laparoscopic loop ileostomy after which he was discharged home on postoperative day five in stable condition .
the patient died five months after the procedure due to systemic cytomegalovirus infection and seizures .
anal cancer is a relatively infrequent tumor , accounting for less than 2% of all large bowel cancer and less than 2000 cases annually in the united states .
only 1.5% of all malignant melanomas develop in the anorectal region and only 460 cases have been reported in the medical literature .
anorectal melanoma is associated with an extremely poor prognosis despite aggressive surgical therapy . in the literature the average survival rates vary from 9 months to 2.8 years for all patients with only a 10% five - year survival .
( memorial sloan - kettering cancer center ) published 85 cases ; seventy - five percent of patients had tumors greater than 1 cm with a mean survival of only 17 months .
only six patients survived five years , and all of these six had undergone abdominoperineal resection .
interestingly , two of the long - term survivors had mesenteric lymph nodes involved by tumor .
several other authors have found that long - term survival was seen only in patients who underwent abdominoperineal resection and have strongly suggested this procedure for cure .
a swedish group reported that only 2 of 33 patients treated for cure survived for five years .
although one of the two survivors underwent local excision , they found that local recurrences occurred significantly more often after a local excision than after an abdominoperineal resection ( 50% vs. 27% , respectively ) .
other researchers believe that radical surgery does not alter the natural history of a high rate of distant metastasis and , therefore , advocate sphincter - sparing surgery .
siegel et al . , in a review of 30 patients , found that the only two 5-year survivors had been treated with local excision .
similarly , cooper et al . reported that two of six 5-year survivors had local excision .
although melanoma has been successfully used to produce tumor cell lines with increased metastatic capacity from many other experimental tumors , none of the three patients in our small series developed port - site recurrences .
leiomyosarcoma of the anorectum is rare , and wide local excision is the best treatment option .
radiation or chemotherapy , alone or in combination , have not been found to be effective , although they may play a palliative role . as emphasized in a st .
mark 's series , the treatment of choice for leiomyosarcoma of the rectum arising from sites other than the muscularis mucosa is abdominoperineal excision . in this current series , one patient who was treated with a previous wide local excision previously had local recurrence and finally underwent laparoscopic abdominoperineal resection .
although most of these lesions are asymptomatic , complications can include bleeding , obstruction , intussusception and mesenteric cyst formation .
treatment of anorectal kaposi 's sarcoma rarely entails surgery although neither the chemotherapy , radiotherapy , nor immunotheraphy is of proven benefit .
because of the decreased immune function in hiv - infected patients , laparoscopy may be beneficial .
these lesions described in this small series of case reports are infrequently occurring but highly aggressive .
it , therefore , seems logical that if these patients need surgery , they be offered the least traumatic , least immune - system compromising type available .
in addition , therapy which can expedite hospital discharge and minimize disability is desirable in patients with a limited life expectancy .
issues germane to care of carcinomatous lesions , such as port - site recurrences , may not be as relevant in these other tumors .
 objective : numerous concerns have been raised relative to the appropriateness of laparoscopic surgery for cure of rectal adenocarcinomas . however , because of their rarity , little information exists about the role of laparoscopy for other anorectal malignancies . 
 we report the outcome of five patients who underwent laparoscopic surgery for other anorectal malignancies.methods:all patients who underwent laparoscopic surgery for treatment of non - carcinomatous anorectal malignancy were assessed by means of endoscopic , radiological and histopathologic diagnostic tests.results:two patients with anorectal melanoma and one with anal leiomyosarcoma underwent laparoscopic abdominoperineal resection . 
 a laparoscopic loop ileostomy was performed for an hiv - positive patient with rectal kaposi 's sarcoma . 
 another patient with anorectal melanoma had intraoperative identification of distant liver metastasis and therefore underwent diagnostic laparoscopy instead of an intended abdominoperineal resection . 
 there were no intraoperative laparoscopic complications . during the follow - up period 
 three patients who underwent abdominoperineal resection were alive , one of whom had rectal melanoma and developed liver metastasis without local recurrence . 
 the two patients with distant liver metastasis and rectal kaposi 's sarcoma died 46 days and five months after surgery , respectively . 
 there were no port - site or local recurrences.conclusion:laparoscopic abdominoperineal resection for non - carcinomatous anorectal malignancies is technically feasible and avoids many of the concerns associated with attempted curative laparoscopic resection of carcinoma . 
INTRODUCTION
METHODS
REPORT OF CASES AND RESULTS
Case 1.
Case 2.
Case 3.
Case 4.
Case 5.
DISCUSSION
CONCLUSION