Surg Today
Jpn J Surg (1996) 26:42-45
Case Reports
A Case of Transverse Colon Cancer Secondarily Involving the Liver,
Duodenum, and Pancreas
MAKOTOSUZAKI,MASATOKITAGAWA,HIDEAKISAKAI,GOH IKEDA, HIDEKIMACHISHI,and KAZUKIYOUMEDA
Department of Surgery,KinanHospital,4750Atawa,Mihama-cho,Minamimuro-gun,Mie 519-52,Japan
Abstract: A 68-year-old woman presented with transverse
colon cancer invading the liver, duodenum, and pancreas.
The patient underwent a curative resection including a
right hemicolectomy, partial hepatectomy, and pancreati-
coduodenectomy (PD). The pathological examination showed
adenocarcinoma of the colon with a direct extension into the
duodenum, liver, and pancreas. Several lymph nodes were
also involved. The patient is still alive and disease-free 2 years
and 6 months after the operation. This case illustrates that
even in patients with locally advanced colon cancer, a favor-
able prognosis can be obtained by aggressive surgery incor-
porating the resection of the adjacent involved organs.
Key Words: colon cancer, adjacent organ involvement,
combined resection
Introduction
Advanced transverse colon cancer sometimes invades
the liver, duodenum, and pancreas. However, such
advanced colon carcinoma often remains localized and
later develops some nodal or distant metastases. A
cure can be obtained by an aggressive surgical approach
which has been made possible thanks to recent advances
in anesthesia and techniques of intra- and postoperative
care. We herein report a case of transverse colon
cancer invading the liver, duodenum, and pancreas
which was successfully treated by the combination of
right hemicolectomy, partial hepatectomy, and pan-
creaticoduodenectomy (PD).
Reprint requests to: M. Suzaki
(Received for publication on June 29, 1994; accepted on July
14, 1995)
SUIt~RYTOOAY
Springer-Verlag 1996
Case Report
A 68-year-old woman had presented to another hospital
with fatigue 4 months earlier, at which time severe
anemia and cardiomegaly were detected. The patient
was transferred to our hospital on November 9, 1991.
Her temperature was 37.3C, the pulse rate was 110/min,
and the respiration rate was 18/min. The blood pressure
was ll0/80mmHg. The patient showed conjunctival
pallor, but her head and neck were otherwise normal.
The lungs were clear, but a galloping rhythm was noted
on cardiac auscultation. A fist-sized hard, immobile
mass was palpable in the right upper quadrant of the
abdomen. A rectal examination revealed no mass
although the stool specimen was positive for occult
blood. Laboratory findings were as follows: hemoglobin,
4.1g/dl; hematocrit, 15.3%; white blood cell count,
11,600/mm3; total protein, 6.2g/dl; albumin, 2.6g/dl;
GPT, 15 U/l; GOT, 6 U/l; lactic dehydrogenase, 388 U/l;
alkaline phosphatase, 6.1 KA; amylase, 135 U/l; blood
urea nitrogen, 15.3mg/dl; creatinine, 0.8mg/dl; and
serum CEA level, 2.8ng/ml (SW). After receiving
blood and albumin transfusions as well as diuretics,
the patient's general condition improved. Imaging
studies were performed next, and fiberoptic gastro-
duodenoscopy revealed an irregular ulcerated mass in
the second part of the duodenum which was close to the
papilla of Vater (Fig. 1). Hypotonic duodenography
showed a filling defect at the same position. A barium
enema showed the "apple core sign" on the right side
of the transverse colon. Colonoscopy showed and
irregular elevation and narrowing of the lumen. Biopsy
specimens were obtained from the duodenal and colonic
lesions. Abdominal computed tomography (CT)
scanning revealed thickening of the transverse colon
wall which was thought to be malignant invasion of the
duodenal wall and the undersurface of the liver. A
microscopic examiantion of both biopsy specimens
showed adenocarcinoma. Under a diagnosis of tran-
M. Suzaki et al.: A Case of Transverse Colon Cancer
Fig. 1. Duodenoscopic findings showing an irregular
ulcerated mass in the second part of the duodenum.
PAP. VA TER, papilla of Vater
sverse colon cancer invading the duodenum and liver,
surgery was performed on December 12, 1991. The
abdomen was opened via a midline incision. No ascites
or peritoneal dissemination was observed. The primary
tumor was located in the transverse colon near the
hepatic flexure having invaded the undersurface of the
anterior portion of the liver as well as the lateral
duodenal wall. There were some enlarged lymph nodes
43
in the colonic mesentery, but the paraaortic and
superior mesenteric nodes were not involved. First, the
involved liver was resected along with 1 cm of normal
liver tissue, and then the right colon, duodenum, and
pancreas were mobilized to the level of the left side of
the aorta by Kocher's maneuver. After this, an en bloc
resection was done, followed by a right hemicolectomy
and PD. Clinically, the tumor was manifested as Si
(liver and duodenum), P0, H0, N3(+), M ( - ) , stage
IIIb, curA (according to the Japanese Research Society
for Cancer of the Colon and Rectum), 1 which indicated
a curative resection. Alimentary reconstruction was
done in the following order: pancreaticojejunostomy,
choledochojejunostomy, and gastrojejunostomy by the
modified Child's method; and ileocolostomy. A macro-
scopic examination of the resected specimen showed an
8 8cm, ulcerated crateriform tumor which invaded
the duodenum and liver. There was no fistula between
the colon and duodenum (Fig. 2). A histological
examination showed moderately differentiated adeno-
carcinoma with mucus-producing regions overlying the
site of duodenal invasion (Fig. 3). The microscopic
manifestation of the disease was as follows: si (liver,
duodenum and pancreas), lyl, v0, nl, 3(+), a w ( - ) ,
o w ( - ) , stage IIIb (according to the Japanese Research
Society for Cancer of the Colon and Rectum). ~ A
curative resection was also indicated based on the
histological findings. The patient developed myocardial
infarction immediately after the operation, but re-
covered with conservative therapy. On the 38th post-
operative day, she suffered from adhesion ileus which
required a partial resection of the small bowel under
epidural anesthesia. After this second operation, she
Fig. 2. Macroscopic findings of the
resected specimen showing an 8 x
8cm, ulcerated crateriform tumor
which had invaded the duodenum
and liver
44
recovered well and remains healthy without recurrence
at 2 years and 6 months postoperatively.
Discussion
The incidence of colon cancer invading the adjacent
organs is reported to be from 7.6% to 12%. 2-4
With respect to such locally advanced colon cancer,
McMahon et al. 5 have stated that mucinous car-
cinoma tends to invade or fistulize to other organs.
The patient reported herein had locally extensive colon
cancer involving the liver, duodenum, and pancreas as
M. Suzaki et al.: A Case of Transverse Colon Cancer
Fig. 3a,b. Histologic findings of the
tumor show moderately differen-
tiated adenocarcinoma (a) with
mucus-producing lesions overlying
the site of the duodenum (b)
well as some mucinous lesions at the site of duodenal
invasion.
There are several operative procedures for transverse
colon cancer involving the duodenum, including bypass
surgery and a right or left hemicolectomy combined
with a partial resection of the duodenum or PD. The
larger the combined resection area the more radical the
operation, and the higher the degree of operative in-
tervention. Consequently, we should choose the most
appropriate operative procedure after carefully con-
sidering the operative risks for each individual patient.
The improved survival of patients with locally
advanced colon cancer after extended surgery is ex-
M. Suzaki et al.: A Case of Transverse Colon Cancer
p l a i n e d in p a r t by t h e r e l a t i v e l y low i n c i d e n c e of
r e g i o n a l l y m p h n o d e m e t a s t a s i s . 6,7 H o w e v e r , o u r p a t i e n t
a c h i e v e d l o n g - t e r m survival d e s p i t e d e m o n s t r a t i n g
positive lymph nodes. Thus, when circumstances permit,
e x t e n d e d s u r g e r y can be r e c o m m e n d e d . I n d e e d , H o j o 8
r e p o r t e d t h a t t h e 5 - y e a r survival r a t e after a c o m b i n e d
r e s e c t i o n of c o l o r e c t a l c a n c e r t h a t h a d i n v a d e d o t h e r
o r g a n s (including P D ) was 54% (for c o l o n c a n c e r o n l y ,
t h e r a t e i n c r e a s e d to 6 5 % ) . E l d e r et al. 2 also r e c o m -
m e n d e d an a g g r e s s i v e surgical a p p r o a c h to locally
invasive c o l o r e c t a l lesions, b e c a u s e an e x t e n d e d re-
section c o u l d a c h i e v e a 5 - y e a r survival r a t e e q u a l to
t h a t for all p a t i e n t s h a v i n g c a r c i n o m a of the c o l o n a n d
r e c t u m . M o r e o v e r , W e l c h et al. 9 r e p o r t e d t h e case of a
14-year survival a f t e r a c o l e c t o m y with P D for c o l o n
cancer invading the duodenum.
Thus, in cases w h e r e a cure o f locally a d v a n c e d colon
c a n c e r is p o s s i b l e , a f a v o r a b l e p r o g n o s i s s h o u l d be
o b t a i n e d by aggressive s u r g e r y i n c o r p o r a t i n g a c o m b i n e d
r e s e c t i o n o f t h e a d j a c e n t i n v o l v e d organs.
45
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