Abstract
Locally advanced colorectal tumors represent about 5–22% of all colorectal cancers at the time of presentation. Specifically in the case of right colon cancer, the percentage of adjacent structure involvement ranges between 11% and 28%. Organs that are most frequently invaded by right colonic tumors are the duodenum and the pancreatic head. We report the case of a 36-year old man with locally advanced right colonic cancer, invading the head of the pancreas and the superior mesenteric vein, who was successfully treated in our department with right hemicolectomy, pancreatoduodenectomy and short resection of the superior mesenteric vein with an end-to-end anastomosis, and remains alive and well, free of disease, nine years after the operation.
Keywords: Locally advanced colonic cancer, Right hemicolectomy, Pancreatoduodenectomy
1. Introduction
Locally advanced colorectal tumors represent about 5–22% of all colorectal cancers at the time of presentation.1 Specifically in the case of right colon cancer, the percentage of adjacent structure involvement ranges between 11% and 28%, but only a few series have reported adjacent organ resection.2–5 In these cases there is a local treatment failure rate of 36–53% following complete resection.6 Invasion of the duodenum or the head of the pancreas poses a rather challenging problem even to the skilled surgeon.
We report the case of a 36-year old man with locally advanced right colonic cancer, invading the head of the pancreas who was successfully treated in our department with right hemicolectomy and pancreatoduodenectomy and remains alive and well, free of disease, nine years after the operation.
2. Presentation of the case
A 36-year old male patient was referred to our Department in October 2002 with a history of gastrointestinal bleeding during the past two weeks. The patient had no history of any systemic symptoms, such as fever, or any other significant past medical or family history. Colonoscopy revealed an ulcerative infiltrating tumor in the proximal transverse colon. Histological examination of biopsies taken during the colonoscopy revealed moderately differentiated adenocarcinoma. Computed tomography (CT) scans of the chest and abdomen failed to reveal either distant metastasis or local invasion of adjacent structures and the patient was planned for laparotomy and right hemicolectomy.
Despite the aforementioned CT findings, intraoperatively, contiguous invasion of the head of the pancreas was revealed. Taking into account the patient's young age and good physical status as well as the absence of distant metastasis, it was decided that a wide en bloc resection of the tumor was the treatment of choice. In accordance with these considerations, right hemicolectomy with pancreatoduodenectomy was performed. Furthermore, a short resection of the superior mesenteric vein was undertaken and the continuity of the vein was restored by an end-to-end anastomosis. The postoperative course of the patient was uneventful and he was discharged on the 12th postoperative day. Histology of the specimen confirmed the diagnosis of moderately differentiated tubule-papillary colonic adenocarcinoma, invading the pericolic and peripancreatic adipose tissue and pancreatic head, as well as the superior mesenteric vein. Out of the 48 lymph nodes included in the resection specimen, only one was found to be infiltrated. Surgical resection margins were clear (R0). The patient received adjuvant chemotherapy with 5-Fluorouracil (5-FU) and leucovorin. Follow up was performed at six month intervals and included physical examination, full blood count, liver chemistry and carcinoembryonic antigen (CEA) at each review. Routine CT scanning of the chest and abdomen was carried out annually for three years after primary therapy, and colonoscopy was performed at three-year intervals.
At the 9-year follow up, the patient remains alive and well, free of disease.
3. Discussion
Organs that are most frequently invaded by right colonic tumors are the duodenum and the pancreatic head.7 In such cases right hemicolectomy along with pancreatoduodenectomy is indicated in order to achieve R0 resection. Patients who undergo margin-negative resection display the same survival as patients with no adjacent organ involvement on a stage-matched basis.7–9
Clinical findings and symptoms in patients presenting with locally advanced right colon cancer include gastrointestinal bleeding, anorexia, weight loss and diarrhea. Sometimes, diarrhea may indicate a duodenocolic fistula.
Computed tomography may sometimes reveal a hypodense mass involving adjacent organs. Yet, CT scanning may be unable to detect intra-abdominal metastases because of lesion size, paucity of intra-abdominal fat, contiguity with the primary tumor, ascites, implant location, and adequacy of bowel opacification. In such cases, locoregional invasion is diagnosed during intraoperative evaluation, as in our patient.2
Multivisceral resection must be restricted to patients with good clinical condition and without distant metastasis. Following R0 multivisceral resection, 5-year survival rates up to 55% have been reported. Saiura et al. reported a series of 12 patients, 5 of whom survived for more than ten years without recurrence.10 Specifically in cases of T4 right colon cancer that undergo extended resection with pancreatoduodenectomy, the median disease-free period may reach 54 months. On the other hand, when patients undergo palliative bypass, the mean length of survival is 9 months and, in cases of incomplete resection (R1–2), the mean length of survival is 11 months.4
Based on this specific case as well as our whole experience, we strongly encourage radical resection for locally advanced tumors. In cases of unexpected findings during the operation, it is our opinion that the patient should be referred to a tertiary unit, with experience in multivisceral resections.
4. Conclusion
In summary, en bloc right hemicolectomy with pancreatoduodenectomy for locally advanced right colon cancer, invading the duodenum or pancreatic head, may offer long-term survival in selected cases, provided that free resection margins have been achieved.
Conflicts of interest statement
The authors have no commercial associations or sources of support that might pose a conflict of interest.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Author contributions
All authors have made substantial contributions to all of the following: (1) the acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be submitted.
Open access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
References
- 1.Harish K., Narayanaswamy Y., Nirmala S. Treatment outcomes in locally advanced colorectal carcinoma. Int Semin Surg Oncol. 2004;1(1):8. doi: 10.1186/1477-7800-1-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kapoor S, Das B, Pal S, Sahni P, Chattopadhyay TK. En bloc resection of right-sided colonic adenocarcinoma with adjacent organ invasion. Int J Colorectal Dis. 2006; 21(3):265-8. Epub 2005 Jun 7. [DOI] [PubMed]
- 3.Curley SA, Carlson GW, Shumate CR, Wishnow KI, Ames FC. Extended resection for locally advanced colorectal carcinoma. Am J Surg. 1992; 163(6):553-9. [DOI] [PubMed]
- 4.Koea J.B., Conlon K., Paty P.B., Guillem J.G., Cohen A.M. Pancreatic or duodenal resection or both for advanced carcinoma of the right colon: is it justified? Dis Colon Rectum. 2000;43(4):460–465. doi: 10.1007/BF02237187. [DOI] [PubMed] [Google Scholar]
- 5.Perez R.O., Coser R.B., Kiss D.R., Iwashita R.A., Jukemura J., Cunha J.E. Combined resection of the duodenum and pancreas for locally advanced colon cancer. Curr Surg. 2005;62(6):613–617. doi: 10.1016/j.cursur.2005.03.021. [DOI] [PubMed] [Google Scholar]
- 6.Costa S.R., Henriques A.C., Horta S.H., Waisberg J., Speranzini M.B. En-bloc pancreatoduodenectomy and right hemicolectomy for treating locally advanced right colon cancer (T4): a series of five patients. Arq Gastroenterol. 2009;46(2):151–153. doi: 10.1590/s0004-28032009000200014. [DOI] [PubMed] [Google Scholar]
- 7.Curley S.A., Evans D.B., Ames F.C. Resection for cure carcinoma of the colon directly invading the duodenum or pancreatic head. J Am Coll Surg. 1994;179:587–592. [PubMed] [Google Scholar]
- 8.Orkin B.A., Dozois R.R., Beart R.W., Jr., Patterson D.E., Gunderson L.L., Ilstrup D.M. Extended resection for locally advanced primary adenocarcinoma of the rectum. Dis Colon Rectum. 1989;32(4):286–292. doi: 10.1007/BF02553481. [DOI] [PubMed] [Google Scholar]
- 9.Rowe V.L., Frost D.B., Huang S. Extended resection for locally advanced colorectal carcinoma. Ann Surg Oncol. 1997;4:131–136. doi: 10.1007/BF02303795. [DOI] [PubMed] [Google Scholar]
- 10.Saiura A., Yamamoto J., Ueno M., Koga R., Seki M., Kokudo N. Long-term survival in patients with locally advanced colon cancer after en bloc pancreaticoduodenectomy and colectomy. Dis Colon Rectum. 2008;51(10):1548–1551. doi: 10.1007/s10350-008-9318-0. Epub 2008 May 3. [DOI] [PubMed] [Google Scholar]