A 75-year-old man comes to the office due to right-sided abdominal pain. He has also experienced progressive fatigue and an unintentional weight loss of 7 kg (15.4 lb) in the past 2 months. He previously refused to undergo colon cancer screening. Medical and family history are unremarkable. Temperature is 37.4 C (99.3 F), blood pressure is 140/80 mm Hg, and pulse is 80/min. Mucosal pallor is present. There is no palpable lymphadenopathy, and cardiopulmonary examination is unremarkable. The abdomen is soft and mildly tender in the right flank area. Abdominal CT scan reveals a large tumor in the right colon with near obstruction of the colonic lumen as well as a 2.1-cm mass in the right hepatic lobe. Liver biopsy of the mass confirms metastatic colon adenocarcinoma. There is no evidence of other metastases. Which of the following is the most appropriate next step in management of this patient?

Question

A 75-year-old man comes to the office due to right-sided abdominal pain.  He has also experienced progressive fatigue and an unintentional weight loss of 7 kg (15.4 lb) in the past 2 months.  He previously refused to undergo colon cancer screening.  Medical and family history are unremarkable.  Temperature is 37.4 C (99.3 F), blood pressure is 140/80 mm Hg, and pulse is 80/min.  Mucosal pallor is present.  There is no palpable lymphadenopathy, and cardiopulmonary examination is unremarkable.  The abdomen is soft and mildly tender in the right flank area.  Abdominal CT scan reveals a large tumor in the right colon with near obstruction of the colonic lumen as well as a 2.1-cm mass in the right hepatic lobe.  Liver biopsy of the mass confirms metastatic colon adenocarcinoma.  There is no evidence of other metastases.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient has adenocarcinoma of the colon with metastatic spread limited to the liver. Liver metastasis is present at the time of diagnosis in up to 25% of cases; the liver is the most common location of colon cancer metastasis because the venous system of the colon drains directly into the portal circulation, facilitating intrahepatic spread. venous system of the colon Whenever possible, patients with adenocarcinoma of the colon should be offered surgical resection with curative intent. When metastatic spread is confined to the liver, surgical resection of both the hepatic mass and the primary tumor can be curative, and often provides increased long-term (>5 yr) survival even when not curative. Metastatic resection is typically done without chemotherapy unless the tumor is deemed unresectable due to the size and/or number of metastatic liver lesions. Resection of the primary tumor is also indicated, regardless of stage, for relief or prevention of obstruction in patients at risk, such as this patient with near obstruction of the lumen. (Choices A and B) Chemotherapy is commonly employed to prolong survival in patients with unresectable metastatic colon cancer. However, for patients with limited liver metastasis, it is not curative and is not preferred over surgical resection. Combined chemotherapy and radiation are used for nonoperable rectal adenocarcinoma as well as anal squamous cell carcinoma; however, radiation therapy is typically avoided in tumors proximal to the rectum because the adverse effects (eg, radiation enteritis) can be severe. (Choice C) Although liver transplantation can help certain individuals with hepatocellular carcinoma, it is contraindicated in patients with primary nonhepatic tumors and would not be offered to this patient. (Choice D) Because surgical resection of isolated liver metastases from colon cancer is potentially curative, offering palliative care only would be advisable if the patient is too frail to tolerate an operation. Although this patient is elderly, he lacks significant comorbidities (eg, cirrhosis, cardiopulmonary disease) that would prevent him from undergoing surgery. Educational objective: The liver is the most common organ affected by metastatic colon adenocarcinoma. Surgical resection can be curative when metastatic colon cancer is confined to the liver. Regardless of stage, resection of the primary tumor is recommended for patients with obstruction or threatened obstruction of the colonic lumen. References: Hepatic metastasis from colorectal cancer. (http://www.ncbi.nlm.nih.gov/pubmed/29201802)

A 75-Year-Old Man Comes to the Office Due to Right-Sided Abdominal