A 50-year-old man was found to have a 70 percent circumferential rectal adenocarcinoma, 10 centimeters from the anal verge, with no evidence of lymph node involvement on transrectal ultrasound. CT concurrently showed a solitary, unilobar, 3-cm left liver lesion, with no other sites of visible metastases. He was considered to be a candidate for immediate resection of the primary tumor and metastasis. Intraoperatively, a porta hepatis lymph node was palpated, but found to be benign on frozen section, and intraoperative ultrasound revealed no additional liver lesions. The patient underwent a simultaneous left lateral segmentectomy and low anterior resection. Final pathology confirmed a T2 rectal lesion with 12 negative lymph nodes. The patient completed postoperative chemotherapy with FOLFOX and bevacizumab.
Case Discussion:
DR PETRELLI: This was a 50-year-old Caucasian man who presented with 70 percent circumferential rectal adenocarcinoma, 10 centimeters from the anal verge, and a synchronous 3-cm lesion in segment II of the liver. Transrectal ultrasound and a CT scan revealed a T2N0 tumor and confirmed the solitary, unilobar left liver lesion.
We planned to perform surgery at both sites, provided that we did not find additional lesions in the liver or any extrahepatic disease. At the time of surgery, no extrahepatic disease was identified. A porta hepatis lymph node was palpated and was sent for frozen section examination. The frozen section was negative for metastasis, and intraoperative ultrasound revealed no other lesions except for the single 3-cm lesion in segment II of the liver.
The patient simultaneously, underwent a low anterior resection and a left lateral segmentectomy and fared well postoperatively. If a patient required a larger operation in the liver, I would not perform that at the same time as a lower anterior resection. I would conduct the lower anterior resection first, stage the disease pathologically and then perform the liver resection, because both the right hepatic lobectomy and the lower anterior resection are major operations, so I would perform the procedures in two separate stages. I did not administer any type of preoperative chemotherapy because the tumor was N0, but it the patient had had node-positive disease or a T3 lesion, we would have recommended preoperative chemoradiation therapy to the rectal lesion for about five weeks. Several weeks after, we would perform the surgery.
This patient did not undergo a large operation. If he would have required anything more than a wedge or a noncomplicated segmentectomy, such as a left lateral segmentectomy or a segment VI segmentectomy, I would have performed the surgery in two stages. Although my colleagues are a bit more aggressive, I feel it’s often safer to perform it as a staged procedure. For example, if a patient had four lesions in the right lobe and a T3 lesion or had node-positive disease, we would treat with preoperative chemoradiation therapy, and then repeat the CT scan eight weeks later. If the CT scan showed additional lesions in the left lobe, I would not be anxious to operate. That patient would receive chemotherapy again to treat the disease systemically or try to convert him to resectable status.
The final pathology on the rectal lesion revealed that it was indeed a T2 tumor. Twelve lymph nodes were negative in the rectal specimen. A combination of FOLFOX and bevacizumab was recommended for postoperative therapy, approximately one year ago. The patient is expected to return to the clinic shortly.
The decision to use FOLFOX and bevacizumab was made by a multidisciplinary team that included a radiologist, a genetic counselor, a nurse navigator and a clinical trials nurse. In this day and age, all patients need the multidisciplinary approach, especially in patients with colorectal cancer and liver metastases. Decisions for these patients must be made using a multidisciplinary approach. The decisions can’t be made by the surgeon alone or the medical oncologist alone or in rectal cancer cases, with the radiation therapist alone.
