An asymptomatic 52-year-old man is evaluated for a nonobstructing mass in his left colon (32 cm from the anorectal verge) found on routine screening colonoscopy. There were no other lesions. The mass was biopsied and diagnosed as grade II colon adenocarcinoma. His other medical problems include hypertension treated with lisinopril and amlodipine. The patient is a former smoker with a 20-pack-year history. He drinks 1 or 2 cans of beer per week. His father died of lung cancer at age 80.
Temperature is 36.7 C (98 F) , blood pressure is 140/80 mm Hg, pulse is 72/min, and respirations are 18/min. BMI is 25 kg/m². Lungs are clear to auscultation. No enlarged lymph nodes are present. Abdominal examination reveals no masses. The liver span is normal, and the spleen cannot be palpated.
Laboratory results are as follows:
CT scan of the chest, abdomen, and pelvis shows a 2.5-cm left colonic lesion that appears to invade the serosa and an enlarged 1.5-cm adjacent lymph node. Two 1.5-cm masses with irregular borders are seen within the right lobe of the liver close to, but not abutting, the capsule. There are no other imaging abnormalities.
Which of the following is the most appropriate course of action in management of this patient?

Question

An asymptomatic 52-year-old man is evaluated for a nonobstructing mass in his left colon (32 cm from the anorectal verge) found on routine screening colonoscopy. There were no other lesions. The mass was biopsied and diagnosed as grade II colon adenocarcinoma. His other medical problems include hypertension treated with lisinopril and amlodipine. The patient is a former smoker with a 20-pack-year history. He drinks 1 or 2 cans of beer per week. His father died of lung cancer at age 80.
Temperature is 36.7 C (98 F) , blood pressure is 140/80 mm Hg, pulse is 72/min, and respirations are 18/min. BMI is 25 kg/m². Lungs are clear to auscultation. No enlarged lymph nodes are present. Abdominal examination reveals no masses. The liver span is normal, and the spleen cannot be palpated.
Laboratory results are as follows:

CT scan of the chest, abdomen, and pelvis shows a 2.5-cm left colonic lesion that appears to invade the serosa and an enlarged 1.5-cm adjacent lymph node. Two 1.5-cm masses with irregular borders are seen within the right lobe of the liver close to, but not abutting, the capsule. There are no other imaging abnormalities.
Which of the following is the most appropriate course of action in management of this patient?

Quizplus · Accepted Answer

11ec193a_97fd_4c08_853d_5753f59db785_MD0002_00 Approximately 20% of patients with colorectal cancer have metastatic disease at diagnosis. Common sites include the liver, lung, peritoneum, and lymph nodes. Most cases are incurable, but patients with liver-isolated colorectal cancer can sometimes be cured with surgical resection. Surgery can generally proceed if <70% of the liver is involved and there is no evidence of hepatic artery, major bile duct, main portal vein, or celiac/para-aortic lymph node disease. Subsequent chemotherapy should then be offered to maximize cure rates (~30%) and 5-year survival (~50%). Lung lesions and metachronous liver metastasis (found after colorectal surgery) are also typically resected with curative intent. This patient with 2 liver lesions in a single lobe, a small primary tumor, and no other significant comorbidities is likely a good candidate for concurrent colorectal and hepatic resection followed by chemotherapy. After treatment, all colorectal cancer patients require regular follow-up with carcinoembryonic antigen testing, colonoscopy, and abdominal imaging to monitor for disease recurrence. (Choice A) Most hepatic metastases are diagnosed by noninvasive imaging and serum tumor markers. Hepatic biopsy adds little to overall diagnostic information and may reduce long-term survival. (Choice B) Chemotherapy alone would provide 5-year survival rates of only ~10% and a minimal chance of cure. Hospice would not be indicated at this time as many treatment options are available, and the patient's overall disease burden is low. (Choice C) Chemotherapy followed by surgical assessment is used for those who do not initially qualify for concurrent surgical resection due to tumor invasiveness (eg, >70% of liver, portal vein involvement). For those with resectable hepatic lesions (as in this patient), surgery should be performed prior to chemotherapy due to the risk of chemotherapy-induced hepatic damage (eg, steatosis), which can limit the ability to operate. (Choice E) Surgical resection followed by chemotherapy results in better long-term outcomes than does surgical resection alone. Educational objective: Patients with colorectal cancer who have resectable liver metastases should be offered surgery followed by chemotherapy with curative intent. __________ References: Liver resection for colorectal metastases in presence of extrahepatic disease: results from an international multi-institutional analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21136180) Trends in long-term survival following liver resection for hepatic colorectal metastases. (http://www.ncbi.nlm.nih.gov/pubmed/12035031)

An Asymptomatic 52-Year-Old Man Is Evaluated for a Nonobstructing Mass