Complex pattern of colon cancer recurrence including a kidney metastasis: A case report

Abstract

We report a case of a 77-year-old female with a local recurrence of cancer after right hemicolectomy which infiltrated the pancreatic head affording pancrea-toduodenectomy, who developed 3 years later recurrent tumor masses localized in the mesentery of the jejunum and in the lower pole of the left kidney. Partial nephrectomy and a segment resection of the small bowel were performed. Histological examination of both specimens revealed a necrotic metastasis of the primary carcinoma of the colon. Although intraluminal implantation of colon cancer cells in the renal pelvic mucosa from ureteric metastasis has been described, metastasis of a colorectal cancer in the kidney parenchyma is extremely rare and can be treated in an organ preserving manner. A complex pattern of colon cancer recurrence with unusual and rare sites of metastasis is reported.

Key Words: Colonic neoplasm, Local recurrence, Kidney metastasis

INTRODUCTION

Adequate resection of colon and mesentery including standardized lymphadenectomy remains the cornerstone of treatment for colorectal cancer[1-3]. Although most patients can be treated surgically with a chance of cure, colorectal neoplasms are still the second leading cause of cancer-related death because 25-50% of the patients suffer from local recurrences or metastasis after complete resection[1,4]. Without adjacent organ invasion and limited nodal disease, local recurrence should be rare depending on technical aspects and quality of the performed operation[5,6]. Among patients with recurrences, the most frequent sites are the liver and the lungs, local and/or regional retroperitoneal and peripheral lymph nodes[7]. Metastases of colorectal cancer in the kidney are considered to be extremely rare. Lee did not identify renal metastasis when analyzing colorectal tumor manifestations in the genitourinary tract[8].

CASE REPORT

In July 1998, 6 mo after laparoscopic cholecystectomy, a 77-year-old female presented herself having a palpable mass in the right upper abdomen with a heavy loss of weight. CT scan showed a tumor involving the right colonic flexure. Colonoscopy revealed an adenocarcinoma, which was intraoperatively found to be perforated locally. Right hemicolectomy and resection of the anterior wall of the duodenum were performed and a highly differentiated adenocarcinoma without lymph node involvement was found histologically. Due to the negative lymph node status, no adjuvant therapy was initiated.

Again 6 mo later a local recurrence at the anastomosis was diagnosed with infiltration of the head of the pancreas. This situation afforded re-resection including a pylorus-preserving pancreatoduodenectomy. No lymph node involvement was found and the TNM tumor stage was rpT3, G2, N0 and M0. CEA levels were normal postoperatively, adjuvant therapy was started with standard intravenous administration of 5-FU/FA for 6 mo.

In October 2001, two tumor sites were found in a MRI localized in the mesentery of the jejunum and in the lower pole of the left kidney. Partial nephrectomy and a segment of the small bowel were done. Histological examination of the kidney specimen as well as of the mesentery of the jejunum showed necrotic metastasis of the colon carcinoma in the kidney with a size of 2.5 cm in diameter. The patient refused any further adjuvant chemotherapy.

In January 2003, multiple jejunal tumors were found in a CT scan, one of them causing complete small bowel obstruction. Because of endoscopic inaccessibility, an open segment resection was needed and performed. Palliative chemotherapy with oral anti-tumor drug administration was started. It was consented not to perform any further surgery. No hepatic or pulmonary metastasis could be found during any hospital stay.

DISCUSSION

In the present case, colon cancer of the right flexure was not diagnosed during laparoscopic surgery. The rate of missed colonic neoplasms during laparoscopic cholecystectomy is reported to be as low as 0.24-0.4%. Because of this low incidence, most surgeons do not screen patients prior to cholecystectomy for colorectal cancer routinely, although careful attention to preoperative physical findings and laboratory data as well as meticulous techniques during laparoscopic cholecystectomy is regarded to be essential to identify patients with concomitant malignant disease[9,10]. If cancer of the colon is overseen during an initial operation, 46% of the patients are readmitted during the first, and another 30% during the second year postoperatively[11]. In these advanced cases, extended surgical procedures such as hemicolectomy with duodenal or pancreatic resection have been shown to be adequate, since they can be performed safely with an increased survival time[12]. In the present case, local tumor growth could not be controlled by the surgical procedure, thus a local recurrence infiltrating the anastomosis was seen 6 mo after primary resection of the tumor.

Isolated anastomotic recurrence is rare after resection of colonic lesions, but more common for rectal cancer, whereas the average time for anastomotic recurrence is about 16 mo[13]. In the case of local or distant recurrent disease, 20% of the patients can be reoperated upon with curative intent, a solitary lesion being a favorable prognostic factor[14,15]. The purpose of postoperative follow-up after curative resection is to identify recurrences at an early and localized stage, because surgical excision remains the only effective treatment, although a substantial impact of any tumor follow-up has been questioned. Nevertheless, using computed tomography and frequent measurements of serum CEA or both, an absolute reduction in mortality of 9-13% can be achieved[16,17].

Localizations of distant colon cancer recurrences are most likely the liver and the lungs, but also metastasis to other organs, such as the thyroid gland or the spleen, has been described[18,19]. In combination with metastasis to the ureter, intraluminal implantation of colon cancer cells in the renal pelvic mucosa has been discovered[20]. Only one case of an intraluminal renal metastasis of a carcinoma of the rectum has been described before[21].