A 38-year-old woman with rectal cancer, synchronous bilateral liver metastases and a left pulmonary metastasis underwent chemoradiation therapy, followed by second-line ralitrexed/oxaliplatin and a subsequent low anterior resection of the primary cancer. Postoperatively, she began yet another systemic regimen — irinotecan/cetuximab — yielding a partial response to her residual liver and lung disease. She self referred to a tertiary center for further surgical evaluation. Given her young age, she was brought to attempted liver resection and underwent right hepatectomy and nonanatomical resection of her left lobe lesions. Extensive lymphadenectomy revealed involvement of the celiac and pedicle lymph nodes. She reinitiated cetuximab/irinotecan postoperatively, but developed a hepatic recurrence within six months and received a second hepatectomy, followed by removal of her persistent lung nodule. Subsequently, she switched to FOLFOX/bevacizumab but again developed a new, unresectable intrabiliary recurrence. The patient survived five years from diagnosis.
Case Discussion:
This was a 38-year-old woman who presented with a rectal tumor, synchronous bilateral liver metastases and a left lung metastasis. She underwent an anterior resection of the rectum and annexectomy after treatment with raltitrexed/oxaliplatin. She had received second-line treatment with FOLFIRI after disease progression. She also received a third line of chemotherapy. She was in partial response for the first time as a significant decrease of the tumor markers was observed. At that time, she requested surgery.
During surgery in July 2004, we found involvement of the pedicle and celiac lymph nodes in addition to a large metastasis of the right liver, 10-centimeter in size, and approximately 10 metastases in the left liver. Although she wasn’t the ideal surgical candidate, we decided to perform an extensive operation because she was young and we were able to remove all of the tumors. We performed an extensive lymphadenectomy, a right hepatectomy and large two segmentfor additional resection of 10 metastases of the left lobe. She did not require intercurrent portal vein ligation as the procedures were all performed during the first stage.
It is not wise to operate on a patient who has hepatic metastasis with lymph node involvement, so patients that present with lymph node involvement should be treated with neoadjuvant chemotherapy before surgery. If a patient has portal lymph node involvement and does not respond to chemotherapy, I would not proceed. We should only operate in those who respond to chemotherapy. In a recent Journal of Clinical Oncology paper, we described the outcomes of patients treated with neoadjuvant chemotherapy who responded to chemotherapy. The message is that those with lymph node involvement of the hepatic pedicle had a 25 percent 5-year survival after surgery, while those with celiac or retroperitoneal lymph node involvement had a zero percent 5-year survival. Therefore, we should proceed with surgery in patients with a hepatic lymph node metastatic location, but we should not operate if patients have involvement in the celiac or retroperitoneal lymph node, even if they respond to chemotherapy.
Consequently, the patient continued to receive chemotherapy with irinotecan and cetuximab postoperatively, but still developed hepatic recurrence at six months after surgery. Although we planned to remove the lung nodule, the hepatic recurrence had to be addressed first during another hepatectomy in March 2005. During the removal of the metastasis, a second lesion was found, and she had also biliary invasion. The postoperative course was uneventful, and she was treated with FOLFOX and bevacizumab postoperatively. Because the impact of K-ras status was not described in 2005, her K-ras status was not evaluated.
In August 2005, she underwent surgery for the lung metastasis and developed a new intrabiliary recurrence a few months later. The new hepatic recurrence was not treatable surgically. She died in August 2008. Although a cure was not possible, she survived five years after her diagnosis with a relatively good quality of life.
The decision to treat a patient with high-risk disease — rectal cancer with synchronous bilateral liver metastases and extrahepatic disease in the lung — is sometimes modulated by the wishes of the patient. This 38-year-old patient wanted to be treated aggressively, and she did not have a high-risk of morbidity and mortality. Sometimes, it is appropriate to treat aggressively, knowing that cure is not possible.
Frankly, when I found involvement of the pedicle and celiac lymph nodes, I knew that this patient would probably not be alive long term, and I debated about whether to continue the surgery. The deciding factors were that the risk was minimal, since she was young, and that she strongly wished to receive the most active treatment possible. However, I would not recommend that all similar patients undergo surgery.
