A 55-year-old active woman in seemingly excellent health presents at the emergency room with abrupt onset of abdominal pain and bloating. CT shows a near-obstructing mass in the distal colon, bilateral liver metastases and questionable peritoneal metastases around her ovaries. She underwent placement of a colonic stent and her abdominal symptoms resolved within a day. She then began preoperative FOLFOX and experienced rapid shrinkage of her primary mass and metastases. By completion of eight cycles of FOLFOX, she experienced marked regression of her liver disease and the apparent peritoneal metastases from the original scan had disappeared. She proceeded to exploratory laparotomy, a left hemicolectomy to remove the primary mass, a right hepatectomy and a wedge resection of the left liver lobe. No evidence of peritoneal disease was found. Pathology showed a Grade III K-ras wild-type colon tumor invading into subserosal fat, but 24 negative regional lymph nodes. However, two of 10 perihilar nodes were positive for metastases. A six week postoperative scan revealed new pulmonary nodules and a mass in the pelvic gut. She was then treated with FOLFOX and bevacizumab.
Case Discussion:
This was a 55-year-old woman with Stage IV colon cancer who presented in the emergency room with a fairly abrupt onset of abdominal pain and bloating. The CT scan showed an apparent near-obstructing mass in the distal colon, bilateral liver metastases and peritoneal metastases around her ovaries.
The feeling was that her disease was beyond surgical resection because she had disease in both sides of the liver, peritoneal disease and a mass in the colon. Both a general surgeon and a colorectal surgeon agreed that, at least initially, surgery was not an option, other than if needed for palliative reasons. Given the amount of disease in her liver, there was concern that if she underwent colon surgery to relieve the obstruction, chemotherapy would be delayed at least four weeks and, if there were any complications, potentially longer. We considered our options for relieving the obstruction and moving on to chemotherapy as quickly as possible. A colonic stent was placed, and all of her abdominal symptoms resolved. Her bowel function returned to normal.
After recovering from the placement of the stent, she began to receive FOLFOX. We planned to add bevacizumab if she responded. She had marked regression of her liver metastases after eight cycles of FOLFOX, and what had been noted as peritoneal metastases previously had disappeared on her scan, so it was not clear if they were truly sites of metastatic disease. Since she has such a good response, the feeling was to proceed with surgery and resect what was there. Since surgery was now a possibility, we elected not to administer bevacizumab in addition to the FOLFOX.
She underwent an exploratory laparotomy, a left hemicolectomy to remove her primary tumor, a right hepatectomy to remove all the disease in the right portion of the liver, and a subsegmental resection or wedge resection of what was in the left lobe. Importantly, no evidence was present of any peritoneal disease.
The pathology report revealed that a tumor was still present in the colon, but all the lymph nodes were negative. The lymph nodes resected around the hilum of the liver showed that two of 10 had metastatic disease. In older series, perihilar adenopathy was always a bad risk factor for patients, and they had a much higher likelihood of recurrent disease. Five years ago, it was an absolute contraindication to surgery, and now it’s a concern, but more people are proceeding with surgery, even if lymph nodes in the porta hepatis demonstrate evidence of metastatic disease. So at least in her case, it raised concern that she was at risk, because this is kind of metastases of the metastases.
Because she was at high risk for recurrent disease, we planned to administer more chemotherapy after surgery. A scan conducted six weeks after surgery showed that she had new pulmonary nodules and a new mass in the left pelvic gut. This all developed rapidly after her surgery, which was discouraging.
The influence of surgery on the growth or spread of metastatic disease is controversial. Does surgery have any influence on the growth or spread of metastatic disease? According to folklore, if the tumor is exposed to air during surgery, it causes the tumor to progress. A more scientific rationale might be that a lot of growth factors are released during surgery, particularly in liver surgery, possibly influencing the rapid regrowth of micrometastatic disease — we’ll never know.
As a result, she received stop-and-go therapy with FOLFOX and bevacizumab for about four to five months, and then capecitabine alone.
The patient spends a good portion of her time in Europe, and so received her FOLFOX and bevacizumab in the United States and then the capecitabine alone when she went to Europe. Although she had good shrinkage of her disease, and was asymptomatic, her lung nodules progressed about six months ago, so treatment was switched to FOLFOX and cetuximab (she was wild-type), and she had marked shrinkage. Recently, treatment was switched back to capecitabine. Other than maybe a little bit more in the way of some cytopenias, she’s had almost no neuropathy.
At this time, she has been alive for close to 20 months after the time of diagnosis.
