|Year : 2018 | Volume
| Issue : 1 | Page : 29-31
Sternal metastasis from a rectal cancer
Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
|Date of Submission||05-May-2017|
|Date of Decision||02-Jun-2017|
|Date of Acceptance||07-Jul-2017|
|Date of Web Publication||09-Feb-2018|
Dr. Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Chennai - 600 036, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Colorectal cancers commonly metastasize to the liver and the lung; it is distinctly unusual for these cancers to metastasize to the skeletal system. The typical locations of skeletal metastases from colorectal cancer are the vertebrae and pelvis. Sternal metastasis from a rectal cancer primary is exceedingly rare, and to the best of our knowledge, there are only two prior case reports in literature. The presence of distant metastases usually portends a poor prognosis, however with continuous improvements in multimodality management, the survival rates of metastatic colorectal cancers has considerably improved. We present an interesting case of a 71-year-old man who underwent a complete metastatectomy for a metachronous sternal metastasis from a locally advanced rectal cancer and discuss its clinical presentation and management implications with a brief review of literature.
Keywords: 18F-fluorodeoxyglucose positron emission tomography-computed tomography, carcinoma rectum, prognosis, sternal metastasis
|How to cite this article:|
Krishnamurthy A. Sternal metastasis from a rectal cancer. Formos J Surg 2018;51:29-31
| Introduction|| |
Accounting for just about 5%–11% of all osseous metastases, skeletal metastases from colorectal cancers are rare, unlike primaries from the breast, thyroid, lung, kidney, and prostate cancers which commonly metastasizes to the skeleton. The typical locations of skeletal metastases from colorectal cancer are the vertebrae and pelvis; sternal metastasis are exceedingly rare.,,, Sternal metastasis from a rectal cancer primary is exceedingly rare, and to the best of our knowledge, there are only two prior case reports in literature. We present an interesting case of a 71-year-old man who developed a sternal metastasis from a locally advanced rectal cancer and discuss its presentation and management.
| Case Report|| |
A 71-year-old man, a diabetic and hypertensive controlled on medications presented with a history of an insidious onset, gradually progressing painless sternal swelling of 4 months duration [Figure 1]. He was previously managed at our center for a locally advanced rectal cancer (cT3N1M0). He underwent neoadjuvant chemoradiation (two cycles of 5FU along with 50 Gray of pelvic radiation) followed by low anterior resection (ypT2N1M0) and completion of the adjuvant chemotherapy (5FU and leucovorin based, which he completed in February 2007). He underwent liver metastatectomy on three different occasions for isolated liver metastasis in 2008, 2011, and 2013 (confirmed each time by 18F-fluorodeoxyglucose positron emission tomography-computed tomography [18F-FDG PET-CT]) and was on regular follow-up after further chemotherapy with oral capecitabine. Poor tolerance to prior adjuvant chemotherapy, elderly age, comorbidities of diabetes and hypertension, and patients preferences were factors considered in the multidisciplinary tumor board decision to consider oral capecitabine. A 18F-FDG PET-CT scan done during the current metastatic workup for a rising carcinoembryonic antigen (CEA), demonstrated an isolated uptake (standardized uptake value-8.7) in the lytic lesion measuring 4.8 cm × 4.6 cm × 4.5 cm involving the mid sternum and the adjacent 4th and 5th ribs with a soft tissue component [Figure 1]. The patient was taken for a wide excision of the sternal and adjoining chest wall lesion after a trucut biopsy confirmation of metastatic adenocarcinoma compatible with a rectal primary [Figure 2]a and [Figure 2]b. The resultant sternal and chest wall defect were reconstructed by a proline mesh and pectoralis major myocutaneous flap for soft tissue cover overlying the mesh [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d. The patient made an uneventful recovery; the final histopathology confirmed the presence of a sternal metastasis from a rectal primary, resected with clear margins. The levels of CEA normalized in the first follow-up (3-month postsurgery). The patient, however, died 9 months post his surgery, due to a noncancer-related event.
|Figure 1: 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan demonstrating an isolated uptake (standardized uptake value-8.7) in the lytic lesion involving the mid sternum and the adjacent 4th and 5th ribs with a soft tissue component|
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|Figure 2: (a and b) Trucut biopsy from the sternal lesion showing malignant cells arranged in sheets, nests showing a cribriform and a glandular pattern, confirming the presence of metastatic adenocarcinoma compatible with a rectal cancer primary|
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|Figure 3: (a) Clinical picture at presentation. (b) Intraoperative clinical photograph following wide excision of the sternal lesion. (c) Intraoperative clinical photograph following reconstruction with a proline mesh. (d) Intraoperative clinical photograph following pectoralis major myocutaneous flap reconstruction overlying the mesh|
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| Discussion|| |
Colorectal cancers commonly metastasize to the liver and the lung; it is distinctly unusual for these cancers to metastasize to the skeletal system.,,, The most common sites for skeletal metastasis are typically within the axial skeleton, and this can at times lead to further skeletal-related events such as bone pains and pathological fractures. The pathophysiology of the skeletal metastasis from rectal cancers possibly involves spread, due to the communication between the Bateson's plexus and the vertebral venous plexus apart from other unknown host and tumor factors.
In a review of 24 patients of skeletal metastasis from rectal cancer primary, a great majority of the patients (about 80%) had a metachronous presentation; the mean time from resection of the primary tumor to the diagnosis of skeletal metastases was around 26 months. In another retrospective review of colorectal cancer patients with skeletal metastasis, no patients had isolated skeletal metastasis at the time of diagnosis and further none of the patients developed skeletal metastasis without yet other organ involvement. Further, the authors suggested a general temporal pattern of colorectal cancer spread after noting that the lung metastasis appeared to be a forerunner of future bone metastasis. The pattern in our patient was, however, different as liver metastasis was seen to be a forerunner to sternal metastasis.
The performance of 18F-FDG PET-CT has a considerable impact on the assessment of patients with colorectal cancers; the impact is the possibly the biggest when used for the detection of previously unrecognized sites of metastatic disease, especially in the setting of rising levels of serum CEA as was repeatedly seen in the course of management of our patient. Systematic reviews and meta-analyses have shown 18F-FDG PET-CT to be more sensitive than CT alone in detecting extrahepatic disease in about 11%–32% of cases, which had resulted in changes the management from a localized curative treatment strategy to a more systemic approach. Incidentally, skeletal metastases of primary colorectal cancers tend to be more frequently diagnosed with the increasing role of imaging studies including PET-CT scans.
The presence of distant metastases usually portends a poor prognosis, however, with continuous improvements in multimodality management, the survival rates of metastatic colorectal cancers has considerably improved. Skeletal metastases in colorectal cancers are believed to be more common in patients with increased numbers of prior active systemic chemotherapeutic agents received. Further, it has been found that the patients who had received either irinotecan or oxaliplatin chemotherapy were significantly more likely to develop skeletal metastases. Regarding the location of the primary tumor, patients with rectal cancers were more likely to develop skeletal metastases than patients with a colonic primary.
The management of skeletal metastases is usually directed toward palliation and involves the combination of surgery (generally in a setting of an isolated resectable metastasis) and chemotherapy/systemic therapy. Several therapies including radiation therapy, neuromodulatory procedures, radiofrequency ablation, cement therapy, and other physical therapies have been used to palliate the pain associated with skeletal metastasis.
The prognosis of patients with skeletal metastases from rectal cancers is ominous, with the average 5 years survival rate being 8.1% and the median survival <10 months. Further, the prognosis of patients with solitary metastases from colorectal cancers is reported to be worst when the metastatic site involves the brain and bone, intermediate in patients with liver metastases, and most favorable in patients with lung metastases.
| Conclusion|| |
As the longevity of the patients with colorectal cancers is increasing owing to remarkable advances in management of the disease across all stages, there is expected to be a parallel increase in the recording of distant metastases, some of which may be a rare site metastasis as was seen in our patient. This knowledge should aid clinicians in expanding their knowledge and understanding of the natural history of these rare metastases and further should help in refining their management strategies and further consider metastatectomies in selected cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]