Our patient is a 65-year-old man who presented initially to the neurosurgery clinic in 8/2011 after noticing difficulty with his vision. His past-medical history was positive only for hypertension. He had no previous surgical history, no prior colonoscopies and no family history of colon cancer. His only gastrointestinal complaint was chronic mild constipation, and he denied any melena, hematochezia, changes in bowel pattern or weight loss. On exam, he was noted to have a left lower quadrant visual field loss (left inferior quadrantanopsia). A brain MRI showed an enhancing lesion in the right occipital lobe. Three days after his clinic visit he underwent a right occipital craniotomy with resection of the tumor, with intraoperative concern for incomplete resection. Pathology results were positive for adenocarcinoma with signet ring features. Tumor cells were positive for CK20 and negative for CK7 and TTF1, suggestive of a colorectal primary lesion.
A CT of the chest, abdomen and pelvis, PET and MRI of the liver were obtained, showing a mass in the proximal ascending colon and pericolonic adenopathy but no other evidence of metastatic disease. A colonoscopy demonstrated an ascending colon mass and biopsies of the lesion revealed poorly differentiated adenocarcinoma with signet ring features. CEA was markedly elevated at 140.8 ng/mL. Three weeks after the brain metastasis resection, he underwent a laparoscopic right hemi-colectomy. Pathology confirmed moderately differentiated adenocarcinoma extending into the pericolonic fat. The surgical margins were negative for tumor, and one of thirty-one lymph nodes was involved by adenocarcinoma. The cancer was classified as stage IV disease by virtue of the central nervous system (CNS) metastases (T3 N1a M1a). The patient underwent stereotactic radiosurgery (SRS) targeted to the postoperative intracranial tumor bed (5 isocenter plan to dose of 17 Gy) 6 weeks after the initial neurosurgical operation. This was followed by 12 cycles of systemic chemotherapy (FOLFOX). More details please visit:-straensenteret.no knutbrokstad.no sky1.no
Brain MRI at three months after SRS was negative, but at six months from SRS and eight months from initial presentation, there was evidence of tumor recurrence at the occipital surgical site on MRI accompanied by a rise in CEA. He was treated with partial brain fractioned radiation to the operative bed (30 Gy in 10 fractions). Continued surveillance MRI imaging subsequently has shown no evidence of persistent or recurrent disease in the brain.
Following fractionated radiotherapy, patient was offered additional chemotherapy or a watch and wait approach, and elected to defer additional chemotherapy at that time. Surveillance CT imaging of the abdomen was normal until 12 months after presentation when there was evidence of local recurrence at the ileocolonic anastomosis and at two abdominal port sites, again accompanied by a rise in CEA to 828.1 ng/mL. These were treated with surgical excision and a new ileocolic anastomosis created. After recovery, he was treated with FOLFIRI with Cetuximab. The patient recovered and is doing well without evidence of any additional recurrence. Continued surveillance is necessary however as there remains a significant risk of local site recurrence (3-15% ) and intracranial recurrence (up to 50%) in patients with similar treatments. He continues to be followed closely with serial surveillance imaging (body CT and brain MRI), colonoscopy and laboratory studies including CEA, now 29 months after presentation (Dec 2013). He has no neurologic deficits including no sensory, motor, visual or cognitive impairments.