A 64-year-old man diagnosed with Stage II colon cancer underwent a sigmoid colectomy and received six months of adjuvant 5-FU/leucovorin. Almost five years later, he was found to have an elevated CEA, and CT revealed a solitary right lower lung nodule, in addition to two large hepatic metastases, measuring eight and 10 centimeters and occupying much of the right lobe of the liver, encroaching but not involving the left lobe. No additional sites of disease were identified. He underwent immediate extended right hepatectomy followed by six cycles of FOLFOX/bevacizumab. The residual pulmonary lesion was then resected and he received an additional six cycles of postoperative FOLFOX/bevacizumab. He maintains no evidence of disease 18 months after completion of all therapy.
Case Discussion:
DR CURLEY: This was a 64-year-old man who underwent a sigmoid colectomy for Stage II sigmoid colon cancer and received six months of adjuvant 5-FU/leucovorin. Five years later, his CEA was elevated and CT revealed a solitary metastasis in the right lower lobe of the lung in addition to two large right-lobe liver metastases. The patient had no evidence of other extrahepatic disease, other than the solitary lung metastasis.
The two liver lesions were quite large — one was about eight centimeters and the other was almost 10 centimeters, occupying much of the right lobe of the liver. The lesions were encroaching upon the left lobe, so we decided to perform a liver resection as his first treatment. It was clear based on his CT scan that an extended right hepatectomy would be necessary, and he did have an adequate volume in segments I, II and III, so PVE was not required.
The patient had localized nodal metastases, and published data demonstrate that a potential survival benefit exists for patients with two sites of metastatic disease from colorectal cancer — in this case, liver and lung — that can both be resected. Also, studies have been published about patients who present with lung as their only site of metastatic disease. Similar to patients who have hepatic metastases, if the lung metastases can be resected — particularly in concert with either neoadjuvant or adjuvant chemotherapy — they have a five-year survival that’s in excess of 30 percent, and in some series, it is in excess of 40 percent at five years. Unfortunately, the lung data are identical to that of liver metastases in that no randomized prospective trials have been conducted, but rather multi-institution or single-institution studies that have treated a large volume of patients.
He recovered from the extended right hepatectomy and then received six cycles of FOLFOX and bevacizumab. At that point, restaging CT showed that the solitary lung lesion was slightly reduced in size and no other metastatic disease was present. He then underwent a wedge resection of the solitary lung metastasis and received an additional six cycles of FOLFOX and bevacizumab. He is now approximately 18 months out from the completion of all therapy, including his chemotherapy, with no evidence of recurrent or new metastatic disease.
In this patient, the liver resection was conducted ahead of the pulmonary metastasis resection because I was more concerned about the liver metastases. The larger of the two liver lesions encroached on both the right and the middle hepatic vein, necessitating an extended right hepatectomy. It would not have required much growth for the left hepatic vein to have been involved also. We did not want to risk the possibility that this patient’s disease could progress during systemic chemotherapy, causing a missed window of opportunity for resection. So we performed the resection of the liver lesions first, allowed him to recover, then did chemotherapy. The lung lesion was small and asymptomatic, only about 2 to 2.5 centimeters in size at presentation. It was the large liver metastases that were our gravest concern initially. At times, we resect the lung and the liver at the same time. In this patient’s situation, based on the volume of resection, we felt that a combined approach was not feasible.
In most patients with Stage II colon cancer, many physicians only follow serum CEA after two to three years. Many feel that the cure rate for patients with Stage II tumors who receive proper surgical therapy and adjuvant therapy is high, so only standard chest radiographs are used. Some physicians would simply evaluate the CEA level on a semiannual or annual basis. I would have to say that this is an area of continued controversy and that there’s no ready agreement. We tend to be a little bit more aggressive in our follow-up at MD Anderson. We will perform CT scans at least annually until a patient reaches five years out, but that’s not certainly agreed on by all practitioners.
