Mikuni Yumeto, Tani Michio, Ichikawa Nobuki, Matsui Hiroki, Emoto Shin, Yoshida Tadashi, Otsuka Takuya, Homma Shigenori, Norihiko Takahashi, Taketomi Akinobu
Department of Gastroenterological Surgery I, Hokkaido University, North 15 West 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
Department of Surgical Pathology, Hokkaido University Hospital, North 14 West 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
Surg Case Rep. 2023 Aug 31;9(1):151. doi: 10.1186/s40792-023-01731-7.
Early-stage colorectal cancer (CRC) is often treated endoscopically, but additional surgical resection may be considered depending on pathological findings.
A 73-year-old man was found to have early-stage sigmoid colon cancer by colonoscopy during a medical examination, and endoscopic mucosal resection (EMR) was performed. The lesion was a 7-mm-sized sessile polyp, and the pathological diagnosis was well-differentiated tubular adenocarcinoma, pT1 (submucosal invasion of 400 μm), with no lymphovascular invasion, low budding grade, and negative horizontal and vertical margins. Therefore, the patient was observed without postoperative treatment. One year later, a computed tomography (CT) scan showed multiple liver metastases. After five courses of preoperative chemotherapy with folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX) and panitumumab, liver metastases were reduced. The patient underwent extended right hepatic lobectomy. The pathological finding was well-to-moderately differentiated tubular adenocarcinoma, and immunohistochemistry findings were consistent with liver metastases from sigmoid colon cancer. Postoperatively, the patient received five courses adjuvant chemotherapy with FOLFOX. Although the patient had been recurrence-free for 5 years after liver resection, a CT scan revealed a nodular lesion in the sigmoid mesentery. Positron emission tomography (PET) showed abnormal accumulation in the same lesion. Therefore, the mesenteric nodules diagnosed as lymph metastasis and recurrence of sigmoid colon cancer and performed laparoscopic sigmoid colon resection with lymph node dissection. The pathological findings showed that the recurrent lesion in the mesentery formed a nodular infiltrate with venous, lymphatic, and neural invasion, but lymph node structures were not found, and it was assumed to be metastasis or recurrence due to lymphovascular invasion. The pathologic specimen of the sigmoid colon had no neoplastic lesions, which are considered to be a local recurrence on the mucosal surface. After sigmoid colectomy, adjuvant chemotherapy with CapeOX was conducted, and the patient has been recurrence-free for 13 months at present.
Even early-stage CRCs that have no pathological indications for additional resection have risks of metastases and recurrences, and we may need to consider that the criteria for additional resection should not be limited to pathological findings alone.
早期结直肠癌（CRC）通常采用内镜治疗，但根据病理结果可能会考虑进行额外的手术切除。
一名73岁男性在体检时通过结肠镜检查发现患有早期乙状结肠癌，并接受了内镜黏膜切除术（EMR）。病变为一个7毫米大小的无蒂息肉，病理诊断为高分化管状腺癌，pT1（黏膜下浸润400微米），无淋巴管侵犯，低芽生分级，切缘水平和垂直方向均为阴性。因此，该患者未接受术后治疗，进行观察。一年后，计算机断层扫描（CT）显示多发肝转移。在接受了五个疗程的亚叶酸、5-氟尿嘧啶和奥沙利铂（FOLFOX）及帕尼单抗术前化疗后，肝转移灶缩小。患者接受了扩大右肝叶切除术。病理结果为中高分化管状腺癌，免疫组化结果与乙状结肠癌肝转移相符。术后，患者接受了五个疗程的FOLFOX辅助化疗。尽管患者肝切除术后5年无复发，但CT扫描显示乙状结肠系膜有一个结节性病变。正电子发射断层扫描（PET）显示同一病变处有异常聚集。因此，肠系膜结节被诊断为乙状结肠癌的淋巴结转移和复发，并进行了腹腔镜乙状结肠切除术及淋巴结清扫。病理结果显示，肠系膜复发灶形成结节状浸润，伴有静脉、淋巴管和神经侵犯，但未发现淋巴结结构，推测为因淋巴管侵犯导致的转移或复发。乙状结肠病理标本无肿瘤病变，考虑为黏膜表面局部复发。乙状结肠切除术后，进行了CapeOX辅助化疗，患者目前已无复发13个月。
即使是早期结直肠癌，若无额外切除的病理指征，也有转移和复发的风险，我们可能需要考虑额外切除的标准不应仅局限于病理结果。
