An educational tool to assist in the management of hepatic metastases in patients with colorectal cancer

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MetResect Cases by Faculty

Using this page you can select cases by the faculty who presented and commented on them.

Cases were contributed and commented on by the following list of physicians. Click on the name to see the case descriptions and then click on the case numbers to see the case discussion and related materials.

René Adam, MD (Cases 23, 24, 25, 44, 51)

CASE 23: A 69-year-old woman presented with colon cancer and a solitary but poorly located, isolated hepatic metastasis in segment VIII of the right hemiliver, abutting the junction of the inferior vena cava, median and right hepatic veins. She underwent a right colectomy at her primary institution, followed by 2 cycles of FOLFOX, and was seen at a tertiary center for surgical consultation, now showing some evidence of liver toxicity and slight disease progression while receiving chemotherapy.

CASE 24: A 50-year-old man with rectal cancer and synchronous hepatic metastases underwent a low anterior resection of the primary tumor and received postoperative FU/leucovorin resulting in disappearance of his liver lesions. One year later, he presented with bilobar liver-only recurrence (1 large lesion in segment VII and multiple small metastases in the left lobe).

CASE 25: A 68-year-old man underwent a colectomy for a sigmoid adenocarcinoma and was found intraoperatively to have bilobar synchronous hepatic metastases. Multiple liver lesions appeared to surround the hepatic vein and inferior vena cava, such that the disease was unresectable at presentation. Patient recovered from his colectomy and exploratory laparotomy without complication.

CASE 44: A 48-year-old woman presented with asymptomatic primary colon cancer and approximately 20 highly distributed bilobar hepatic metastases. Disease was not found outside of the colon and liver.

CASE 51: A 38-year-old woman with rectal cancer, synchronous bilateral liver metastases (one 10-cm lesion in the right lobe, multiple small lesions in the left lobe) and a left pulmonary metastasis underwent chemoradiation therapy, followed by second-line ralitrexed/oxaliplatin and a subsequent low anterior resection of the primary. Postoperatively, the patient began another systemic regimen, irinotecan/cetuximab, yielding a partial response of her residual liver and lung disease. She now self-refers to a tertiary center for further surgical evaluation.

Steven Alberts, MD (Cases 9, 29, 36, 37, 38)

CASE 9: A 54-year-old man initially presents with hemorrhoids and fatigue. Colonoscopy reveals a 5-cm mass in the midrectum. A poor-quality CT scan of the abdomen and pelvis is read as normal. Patient receives neoadjuvant chemoradiation therapy and undergoes a low anterior resection of a Grade III adenocarcinoma. Seven of 8 lymph nodes are positive, but surgical evaluation suggests the abdomen is otherwise normal. A follow-up CT scan obtained 6 weeks postoperatively shows a large mass occupying a substantial part of the peripheral right lobe of the liver. Left liver is of average size and without evidence of metastases.

CASE 29: A 69-year-old Asian man is found to be mildly anemic upon routine checkup for chronic hepatitis B (HBV). Colonoscopy shows a tumor in the sigmoid colon and CT reveals a 1-cm indeterminate mass located in the dome of the liver, which is undetectable by ultrasound. Bilirubin is normal but AST level has doubled from baseline. Patient is otherwise very healthy.

CASE 36: A 39-year-old woman with a 1-year history of rectal bleeding, attributed to hemorrhoids, that preceded and continued throughout pregnancy initially presented postpartum with continued hematochezia. Workup showed a large fungating mass in the rectum and CT evidence of 4 small bilobar liver metastases (1 left lateral, 3 on right within segments V and VII).

CASE 37: 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 (2 large lesions in segments VII and VIII superiorly and a 1.5 cm lesion in left lateral lobe) and questionable peritoneal metastases around her ovaries.

CASE 38: An active 42-year-old man reporting a 2- to 3-year history of intermittent rectal bleeding presents with anorexia, fatigue and a 10-lb weight loss. Exam reveals enlargement of the liver with elevated LFT results, and colonoscopy shows a mass in the sigmoid consistent with colon cancer. CT demonstrates the presence of synchronous multiple (8+), large but potentially convertible metastases in both lobes of the liver, without evidence of extrahepatic disease. ntiated adenocarcinoma with focal signet ring features.

Michael Choti, MD (Cases 10, 16, 17, 46, 47)

CASE 10: A 63-year-old woman underwent a left hemicolectomy and received adjuvant FOLFOX for Stage IIIB cancer of the left colon. Twenty-six months after the original diagnosis, routine surveillance now reveals CEA elevation from a nadir of 1.4 to a current value of 12. PET/CT reveals a solitary 7-cm lesion occupying the central liver (within segments IV, V and VIII). No extrahepatic disease is detected.

CASE 16: A 41-year-old man initially presented with Stage IV colon cancer and underwent a palliative right hemicolectomy. Metastatic disease was confined to the liver but notably occupied most of the right lobe, abutting the inferior vena cava. Several smaller lesions of undetermined significance were found in the left hemiliver. Prior to surgical referral, the patient completed 10 cycles of FOLFOX and bevacizumab, with CEA response but limited radiologic response. He then received transarterial chemoembolization for 2 cycles. He now presents 1 year after the initial diagnosis with isolated hepatic metastases, somewhat unchanged from baseline.

CASE 17: A 51-year-old man presented with anemia, and a colonoscopy revealed cecal cancer. Patient underwent a right hemicolectomy, and pathology confirmed the tumor to be T3N1Mx. He was then referred to a medical oncologist for adjuvant therapy, and staging CT identified 3 hepatic metastases, 1 located centrally, 1 near the right portal pedicle and 1 adjacent to the gall bladder. Uninvolved segments I, II and III represent </= 20% functional liver reserve by volumetric studies.

CASE 46: A 60-year-old man status post right hemicolectomy for Stage II colon cancer presents at 1-year follow-up with rising CEA levels. CT reveals 2 metastases in the peripheral right liver lobe, each measuring less than 2 centimeters. PET confirms the 2 small lesions but also demonstrates uptake in the porta hepatis suspicious of periportal lymph node involvement.

CASE 47: A 75-year-old woman with a history of Stage III colon cancer treated with resection and adjuvant FOLFOX now presents 18 months after initial diagnosis with rising CEA levels. PET/CT indicates 2 liver metastases confined to the right lobe and 2 potentially resectable small left lung metastases.

Steven Curley, MD (Cases 21, 22, 33, 42, 43, 49, 50)

CASE 21: A 54-year-old woman with a history of Stage III colon cancer treated with hemicolectomy and 6 months of adjuvant FOLFOX presents 20 months after resection with elevated CEA and PET/CT evidence of 4 hepatic metastases involving liver segments IV, V, VII and VIII. There appeared to be involvement of the middle hepatic vein and tumor proximity to both the right and left hepatic veins. No extrahepatic disease was identified, but the caudate and left lateral lobe comprised only 18 percent of the total liver volume.

CASE 22: A 60-year-old woman previously underwent a low anterior resection for a T3N0 rectosigmoid tumor with no adjunctive systemic therapy. Three years after resection, she complained of early satiety and CT indicated a large liver metastasis involving segments II, III, IV and VIII, encasing the left and middle hepatic veins and abutting the right hepatic vein. No extrahepatic disease was identified.

CASE 33: A 62-year-old man who recently experienced myocardial infarction and coronary stent placement was found to have heme-positive stool and colonoscopic evidence of a rectosigmoid adenocarcinoma 6 centimeters from the anal verge. Staging CT revealed 2 small, peripheral liver metastases contained within the right lobe but no extrahepatic disease.

CASE 42: A 48-year-old woman presents with elevated CEA levels and a 1-year history of rectal bleeding. Colonoscopy reveals a nonobstructing rectal adenocarcinoma 8 centimeters above the anal verge, and staging CT shows multiple synchronous hepatic metastases in the right hemiliver, appearing to encase the portal vein. No other sites of disease are identified.

CASE 43: An obese 64-year-old woman with insulin-dependent diabetes presents with elevated LFT results and CT evidence of bilobar liver lesions suspicious for metastatic disease involving a significant portion of the right lobe with extension into segment IV. Colonoscopy reveals a nonobstructing adenocarcinoma in the descending colon. No extrahepatic disease was identified.

CASE 49: A 32-year-old man with HNPCC underwent an extended right hemicolectomy for Stage III disease (12 nodes involved). He received 3 months of adjuvant 5-FU/LV but shortly thereafter experienced a CEA rise and PET/CT revealed 3 liver metastases involving segments III, IV and VI in addition to enlarged and FDG-avid porta hepatis lymph nodes. No additional sites of disease were identified.

CASE 50: A 64-year-old man underwent a sigmoid colectomy for Stage II colon cancer and received 6 months of adjuvant 5-FU/LV. Five years later surveillance CT revealed a solitary right lower lung nodule and 2 large hepatic metastases measuring 8 and 10 centimeters and occupying much of the right lobe of the liver, encroaching on but not involving the left lobe. No additional sites of disease were identified.

Axel Grothey, MD (Cases 1, 2, 26, 27, 35)

CASE 1: A 50-year-old woman status post sigmoid resection for Stage III colon cancer treated on protocol with adjuvant FOLFOX and bevacizumab now presents 18 months after initial diagnosis with increasing CEA and radiologic evidence of one 8.4-cm metastasis in the right lobe of the liver (segments VII and VIII). Left liver lobe appears normal in size and without evidence of metastases.

CASE 2: A 59-year-old man underwent a left colectomy for a Stage II obstructing sigmoid tumor shortly following coronary bypass surgery. After a year of observation, surveillance CT revealed 4 hepatic metastases in the right lobe of the liver, somewhat peripherally located, the largest measuring 2.3 centimeters. Left liver lobe appears normal in size and without evidence of metastases.

CASE 26: A 49-year-old man presented with CT/PET evidence of primary cecal cancer with involved regional lymph nodes and small synchronous bilobar liver lesions. PET/CT identified scattered metastases, 6 in the right lobe and 1 in the left lobe, all measuring ≤2 centimeters. Radiologic margins relative to major vessels appeared adequate on assessment.

CASE 27: A 64-year-old woman presented with a partially obstructing mass in her transverse colon found after a routine colonoscopy. Abdominal CT showed evidence of 3 peripherally located (2 centimeters or less) synchronous hepatic lesions in the right liver.

CASE 35: A 57-year-old woman presented with PET/CT evidence of a colonic mass with distention and 12 intrahepatic FDG avid lesions, mainly confined to the superior/posterior aspect of the right lobe but with some minor involvement of segments I and II. Colonic biopsy confirmed the presence of a poorly differentiated adenocarcinoma with focal signet ring features.

Daniel Haller, MD (Cases 12, 19, 20, 31, 32, 48)

CASE 12: A 65-year-old woman diagnosed with T3N2 colon cancer was treated with resection and 10 cycles of adjuvant FOLFOX and switched to 5-FU/LV alone for the final 2 cycles secondary to Grade II neuropathy. Six months after surgery, a rising CEA level was linked to the discovery by CT of new small bilobar hepatic metastases, including a 2-cm lesion within segment VI and a 3-cm lesion within segment III. PET confirmed the findings but ruled out extrahepatic disease.

CASE 19: A 42-year-old man underwent resection for a Stage II T3/N0 colonic tumor, followed by postoperative adjuvant therapy with 5-FU/LV. Three years after diagnosis, surveillance CT revealed a single 3-cm hepatic lesion abutting a major artery in segment VIII of the right lobe. PET showed no other liver involvement and no extrahepatic disease.

CASE 20: A 62-year-old woman was diagnosed 3 years ago with a T3N1 low rectal tumor and received neoadjuvant chemoradiation therapy followed by resection with permanent colostomy and 4 additional cycles of postoperative 5-FU/LV. She now presents with surveillance CT evidence of 5 unique bilobar hepatic metastases, including segments VI, VII, VIII and II. The lesion in segment VIII appears to be flush against a major aortic branch vessel. The 2 tumors in the left lobe are not geographically amenable to radiofrequency ablation.

CASE 31: A 42-year-old woman with hematochezia and altered bowel movements is found to have a T3, node-positive rectal tumor 6 centimeters above the anal verge with 2 synchronous right hepatic lesions in segments V and VII, measuring 3 and 2 centimeters, respectively. PET confirms no evidence of extrahepatic disease.

CASE 32: A 72-year-old man was diagnosed with a T3N1 bleeding low rectal mass and 2 synchronous 3-cm hepatic metastases in segment VI of the right hemiliver. PET showed no evidence of extrahepatic disease.

CASE 48: A 54-year-old obese man underwent resection for T3N2 colon cancer followed by 9 cycles of adjuvant FOLFOX. Two years later a rise in CEA prompted a PET/CT scan, which revealed a solitary 2-cm lung nodule and 3 right-sided hepatic metastases, all measuring less than 3 centimeters. No further disease was identified.

Nicholas Petrelli, MD (Cases 5, 6, 7, 8, 15, 28)

CASE 5: An otherwise healthy 63-year-old man who underwent a left hemicolectomy and adjuvant FOLFOX 3 years prior for lymph node-positive adenocarcinoma of the colon now presents with a serial rise in CEA levels. CT confirms a single 4-cm lesion within segment VI of the liver, with no identifiable extrahepatic disease.

CASE 6: A 70-year-old male smoker with a history of Stage II cecal adenocarcinoma was treated 4 years prior with hemicolectomy (no adjuvant therapy). Surveillance CT identifies 2 lesions in the liver, a 3-cm mass in segment III of the left lobe and a 4-cm mass in segment VII of the posterior right lobe, but no evidence of extrahepatic disease.

CASE 7: An obese, insulin-dependent diabetic 55-year-old man presents 2 years after resection for Stage II sigmoid cancer. During routine follow-up, CT reveals 4 lesions scattered throughout all 4 segments of the right lobe of the liver, ranging in size from 2 to 4 centimeters. Left lobe of the liver appears to be of normal size and without metastases.

CASE 8: A 65-year-old woman presents 4 years after undergoing a right
hemicolectomy and receiving adjuvant FOLFOX for a Stage III adenocarcinoma in the ascending colon. Routine follow-up CT reveals a 3-cm lesion in segment V of the right liver, with no visible extrahepatic disease.

CASE 15: A 72-year-old woman presents 5 years after preoperative chemoradiation therapy and an abdominal perineal resection for a T3N2 adenocarcinoma, complaining of right upper quadrant discomfort. CT shows 8 bilobar liver lesions ranging from 2 to 5 centimeters in size, 2 of which appear to reside in the lateral left lobe and 6 in the posterior portion of the right lobe.

CASE 28: 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 showed a concurrent, solitary, unilobar, 3-cm left liver lesion with no other sites of visible metastasis.

John Primrose, MD (Cases 11, 18, 30, 39, 40, 41)

CASE 11: A 62-year-old man underwent an extended right hemicolectomy for an obstructed carcinoma in the right transverse colon, and tumor deposit was discovered intraoperatively in the omentum, which was also resected. Postoperatively, the patient received 6 cycles of FOLFOX. One year after surgery, surveillance PET/CT reveals an isolated solitary 2.5-cm metastasis in the right liver.

CASE 18: A 48-year-old woman with acute abdominal pain was found to have a pelvic abscess secondary to a perforated sigmoid tumor associated with extensive hepatic metastases. Bilobar liver lesions ranged in size from 1 to 5 centimeters and demonstrated involvement of almost every segment. Emergent abscess drainage and resection of the sigmoid tumor were performed.

CASE 30: A 74-year-old female is diagnosed with a low rectal tumor and multiple synchronous small right liver metastases located within segments VI, VII and VIII.

CASE 39: A 34-year-old female in excellent health presented with primary sigmoid cancer and synchronous extensive, right-hemiliver metastases in addition to PET/CT evidence of an involved perihilar lymph node. No additional extrahepatic disease was identified.

CASE 40: A 76-year-old woman presented with an obstructing tumor in the splenic flexure and large synchronous metastases in the right peripheral hemiliver, with some extension to segment IV. A stent was placed to alleviate the emergent obstruction.

CASE 41: An 80-year-old man presents with a primary nonobstructing cecal tumor and synchronous extensive right-side liver metastases (involving segments V-VIII). The left lobe is notably small and likely represents inadequate hepatic reserve if a complete right lobectomy were to be performed

Alan Venook, MD (Cases 3, 4, 13, 14, 34, 45)

CASE 3: A 60-year-old patient presented with elevated CEA 3 years after resection for Stage II primary colorectal cancer (CRC) treated without adjuvant chemotherapy. Surveillance PET/CT showed a 2-cm lesion in the right liver lobe, centrally located with adequate radiologic margins, and a 0.5-cm accessible lesion in the medial left liver lobe.

CASE 4: A 50-year-old man previously treated for Stage III primary CRC with adjuvant FOLFOX now presents 3 years after initial diagnosis with a solitary 3-cm metastasis in the right liver lobe (segment VI). He continues to experience mild residual treatment-related peripheral neuropathy.

CASE 13: A 40-year-old man initially presents with a transient bleed from a K-ras wild-type primary tumor located in the cecum and is treated with colonic resection, ahead of imaging or CEA evaluation, by a local surgeon. Patient now presents postoperatively with elevated CEA and radiologic evidence of a central solitary metastasis in the right/caudate liver lobe. Left liver lobe appears small but free of metastases.

CASE 14: A 65-year-old woman with stage-unknown CRC previously treated by resection of the primary lesion without systemic therapy now presents 4 years after initial diagnosis complaining of abdominal “fullness.” CT/PET reveals a 6- to 8-cm solitary and centrally located liver metastasis, spanning across both the right and left lobes.

CASE 34: A 38-year-old postpartum woman presents with rectal bleeding lasting a few months, previously attributed to hemorrhoids. She is diagnosed with primary sigmoid cancer with a synchronous, centrally located 5-cm liver metastasis in segment VII.

CASE 45: A 60-year-old man previously treated with adjuvant 5-FU and leucovorin for primary CRC presents 3 years after initial diagnosis with elevated transaminases after undergoing a routine liver function test while receiving cholesterol-lowering medications. CT shows a solitary 4-cm liver lesion in the right lobe and an enlarged porta hepatis node but no other obvious extrahepatic disease. Left lobe appears normal in size and without evidence of metastasis.

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