Intrabiliary growth type of metastasis from colon cancer, 12 years after curative colectomy: a case report

Intrabiliary metastasis of colorectal mucinous adenocarcinoma mimicking choledocholithiasis 18 years after the primary tumor

This case report presents a 62-year-old male who had previously undergone curative colectomy and neoadjuvant chemotherapy in 2005 for colorectal cancer. He presented with jaundice, which was initially attributed to choledocholithiasis. After cholecystectomy and repeat ERCPs, hyperbilirubinemia persisted. There was persistent dilation of the right posterior duct on imaging, concerning for biliary stricture, possibly due to cholangiocarcinoma or intraductal papillary neoplasm. During a right posterior hepatectomy, a peripheral liver lesion was found in association with the dilated bile duct. On frozen evaluation, the lesion was found to be invasive adenocarcinoma. The final pathology was compatible with a metastatic mucinous adenocarcinoma of colonic origin. A repeat colonoscopy was done with no recurrence or new lesion in the colon. This case underscores the challenges associated with diagnosing biliary issues and assessing liver lesions in patients with a remote history of cancer. It raises the question of when and whether, after primary cancer treatment, it becomes safe to explore alternative diagnoses without immediately suspecting metastasis. Another significant challenge arises in ascertaining the most suitable therapeutic approaches for these patients. This is because these extremely late recurrences might be linked to an indolent, slow-growing type of tumor, but also have been linked to cancer stem cells, and as any recurrence, demands attention.

Intrabiliary metastasis of colorectal adenocarcinoma: the SPY perspective

We report a case of a 54-year-old female that underwent sigmoidectomy for stage IIA adenocarcinoma. After 5 years of follow-up, despite normal colonoscopy and CEA and CA-19.9 levels, abdominal CT revealed a 3 cm perianastomotic peritoneal lesion and suspected liver metastasis. Although liver biopsy was negative for malignancy, the perianastomotic lesion was confirmed to be metastasis of colonic adenocarcinoma. After chemotherapy, a mild elevation of alkaline phosphatase and γ-GT was evident. MRCP revealed dilation of intrahepatic bile ducts in segment VIII due to an intraluminal lesion in the right hepatic duct, suggestive of intraductal cholangiocarcinoma.

Imaging and clinical features of colorectal liver metastases with macroscopic intrabiliary growth

PURPOSE

The purpose of this study was to evaluate imaging and clinical features of colorectal liver metastases complicated with macroscopic intrabiliary growth, and correlate the unusual pattern of spread with treatment and follow-up.

METHODS

A retrospective analysis of the clinical, imaging and follow-up files of all patients with surgically resected colorectal liver metastases from January 2016 to October 2020 was reviewed to identify those with macroscopic intrabiliary growth. Two radiologists evaluated the radiological features of colorectal liver metastasis with macroscopic intrabiliary growth. The histopathological findings and follow-up results were also investigated.

RESULTS

A total of 555 patients were included. Colorectal liver metastasis with macroscopic intrabiliary growth was present in 5 patients (0.9 %). Four patients experienced tumor recurrence or progression after surgical treatment (80 %), and recurrent tumors retained propensity for intraductal growth. CT (n = 6) and MR (n = 6) examinations were performed before 8 operations with the pathological examination confirmed macroscopic intrabiliary colorectal metastases. According to the location, intrabiliary colorectal metastases were classified into two categories: peripheral (n = 3) and central involvement (n = 5). The lengths of tumoral extension into the downstream bile duct were more than those of extension into the upstream bile duct (P = 0.029). On CT images, all cases showed dilated bile ducts filled with soft tissue attenuation presenting moderate (n = 4) or obvious (n = 2) enhancement. On MR images, all intra-hepatic and intrabiliary components of the metastases showed restricted diffusion on diffusion-weighted imaging, and peritumoral wedge-shaped T1-weighted hyperintensity appeared in the cases with obstruction of intrahepatic bile ducts.

CONCLUSIONS

The propensity for colorectal liver metastasis with intrabiliary growth to grow longitudinally and extend beyond the intrahepatic tumor edge elevates the risk of high recurrence after operation. Intrabiliary growth of liver metastasis exhibits characteristic MR and CT imaging features, which help to make an accurate diagnosis and improve treatment plans.

Metastatic liver tumor from a primary gastric cancer with infiltration of the Glisson's pedicle: A case report

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A single metastatic liver tumour from a primary gastric cancer is rare.

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Glisson’s pedicle invasion was identified on preoperative MR and PET-CT imaging.

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Surgical resection, with R0 margin, was deemed possible based on imaging results.

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The patient survived, without cancer recurrence for more than 1 year.

Introduction

Metastatic liver tumors from primary gastric cancer are rarely resected because of the high rate of metastasis and recurrence of gastric cancer, and there is little information regarding the pathological assessment of these tumors. We present a case of a single metastatic liver tumor from gastric cancer with invasion of the interlobular bile duct for which we achieved margin-free resection with good clinical outcomes.

Presentation of case

An 80-year-old patient presented with a tumor in segment V of the liver, with invasion of Glisson’s pedicle confirmed on preoperative magnetic resonance and positron emission tomography imaging. On the basis of the preoperative assessment, we proceeded with partial hepatectomy, with transection of one of the roots of Glisson’s pedicle performed under echography guidance. Pathological examination confirmed gastric cancer as the primary source of the metastatic tumor. R0 resection was achieved, with no evidence of cancer recurrence at one year after surgery.

Discussion

Our experience supports partial hepatectomy with R0 margin tumor resection as an oncologically feasible treatment for metastatic liver tumor arising from primary gastric cancer (in the absence of other metastatic lesions) and shows that a good prognosis can be achieved. Of note, intraoperative echography did not detect tumor invasion of Glisson’s pedicle, which was evident only on preoperative imaging.

Conclusion

This case suggests that magnetic resonance and positron emission tomography imaging findings are important for surgical planning of hepatectomy. Further follow-up data and more cases are needed to completely define the clinical significance of tumor invasion of Glisson’s pedicle.