A 60-year-old man status post right hemicolectomy for Stage II colon cancer presents at one year follow up with rising CEA levels. CT reveals two metastases in the peripheral right liver lobe, each smaller than two centimeters. A PET scan confirms this and the two small lesions but also demonstrates uptake in the porta hepatic, suspicious of periportal lymph node involvement. It is recommended that he undergo neoadjuvant chemotherapy followed by resection of metastases.
Case Discussion:
DR CHOTI: This is a patient who was previously treated for colon cancer and had rising CEA levels. The CT scan revealed two resectable metastases in the right liver lobe. The preoperative PET scan confirmed two resectable metastases and further revealed additional uptake in the porta hepatis, most likely indicative of periportal lymph node-positive disease causing the prognosis to worsen.
If both the liver and periportal lymph nodes are positive, the prognosis is worse. One study from Europe suggested that prognosis depends on if the diseased nodes are so-called hilar lymph nodes — not near the portal, but near what’s called the celiac artery. The hilar lymph node location suggests that patients probably don’t fare well at all. If the nodes are right near the portal vein, then occasionally there is a cure.
As recently as five to 10 years ago, we used to define periportal node disease as incurable and felt that surgery should not even be performed. At this time, if you remove those positive lymph nodes, the prognosis is still worse than if those lymph nodes were negative, but occasionally those patients will be cured long term. We think that surgery prolongs survival in those patients. Positive periportal lymph nodes are definitely a poor prognostic factor, but they are not an absolute contraindication to surgery, although the pros and cons of surgical risks need to be weighed carefully. If a patient developed a slow-growing tumor years after their colon cancer, and disease in the liver was stable with one slow-growing periportal positive node, we would certainly operate on that patient — it’s not all or none.
I would be more inclined to use neoadjuvant chemotherapy in the setting of resectable disease with positive periportal nodes. If someone has initially resectable disease with periportal node involvement, I think one could still perform surgery followed by chemotherapy or use chemotherapy first, but I would be more inclined to offer chemotherapy because the tumor biology is more aggressive. If the patient doesn’t respond or if other lesions develop, you have spared the patient from unnecessary surgery.
