A 59-year-old woman was referred to our institution for liver tumors detected on ultrasound. Computed tomography (CT) revealed an enhanced mass in the ascending colon that invaded the abdominal wall and the inferior edge of the liver. The regional lymph nodes (#202, #212, and #221) were distinctly swollen and suspected to be metastatic. There were two metastatic lesions in liver segment 8, and the hilar lymph nodes were also swollen (Fig. 1a, b). Colonoscopy showed a circumferential tumor in the ascending colon, and the scope was unable to pass beyond it (Fig. 2). The tumor marker levels were as follows: carcinoembryonic antigen, 13.7 (upper reference limit, 5.0 ng/dL); carbohydrate antigen 19-9, 2.64 U/mL (upper reference limit, 37.0 IU/mL). Other laboratory data revealed abnormal values of γ-guanosine triphosphate (41 U/L; reference range, 9–32 U/L) and alkaline phosphatase (397 U/L; reference range, 106–322 U/L); levels of all other investigations were within the normal range. Biopsy findings from the primary tumor revealed an adenocarcinoma (tub1 > tub2) and the RAS pattern was mutant. Based on the criteria of the International Union against Cancer Committee (UICC, 8th edition), the diagnosis was ascending colon cancer with multiple liver metastases and the clinical stage was cT4aN1M1a(H), cStage IV.
The patient required curative resection, but as the primary tumor in the colon extended beyond the colonic wall, we decided to administer preoperative chemotherapy before the radical surgery to obtain free radial resection margins. However, as the obstruction was severe, LITB was performed as the initial treatment. LITB was initiated with five ports after confirming the absence of peritoneal dissemination. Subsequently, part of the ileum, 25 cm from the terminal ileum, and the transverse colon were placed together for side-to-side anastomosis. The anastomosis was constructed using linear staplers (Signia Endo-GIA TM, purple 60 mm) after placement of three stay sutures. To prevent peritoneal dissemination and intra-abdominal infection, we covered the stapler device after anastomosis, and the entry hole of the staplers was closed in a hand-sewn fashion using the Albert–Lembert method (Fig. 3).
The surgical time was 98 min, and the blood loss was 5 mL. The patient was discharged on postoperative day (POD) 18 without complications.
Four weeks after the first surgery, preoperative chemotherapy, capecitabine plus oxaliplatin (CapeOX) + bevacizumab, was administered. Five courses of chemotherapy were administered, although a reduction in capecitabine dose was required due to stomatitis (Common Terminology Criteria for Adverse Events Grade 1). CT after preoperative chemotherapy revealed a shrinkage of the primary tumor and metastatic lesion (Fig. 4a, b), although the tumor marker levels remained unchanged. Six weeks after the preoperative chemotherapy, right hemicolectomy with D3 lymph node dissection and right hepatectomy were performed, based on the diagnosis of ascending colon cancer with multiple liver metastases (ycT4aN1M1, ycStage IV). First, the surgery was performed from the liver part, and when the dissection of the liver was complete, the operation was performed from the colon part. Since a side-to-side anastomosis had been performed in the previous bypass surgery, right hemicolectomy was simply completed by resecting the ileum and transverse colon after complete mesocolic excision. The surgical time for colectomy was 90 min, and the blood loss was 30 mL; the total surgical time was 382 min, and the total blood loss was 530 mL. Temporary chylous ascites appeared after the operation, but improved with observation. The patient was discharged from the hospital on POD 15 without complications.
Pathological findings of the resected specimen confirmed that the ascending colon tumor was a moderately differentiated adenocarcinoma with negative resection margins. The effectiveness of chemotherapy was Grade 1a (Japanese Society for Cancer of the Colon and Rectum, 9th edition). Four lesions in segment 8 of the liver were confirmed as metastatic adenocarcinoma with negative resection margins, and the effectiveness of chemotherapy was Grade 2 (Fig. 5A, B). The final pathological diagnosis was ypT3N0M1a(H1), ypStage IVa. After radical operation, the patient did not receive chemotherapy due to liver dysfunction and ascites. She has been alive for 8 months after the surgery, with no evidence of cancer recurrence.