Intraductal papillary growth of liver metastasis originating from colon carcinoma in the bile duct: report of a case

Morphologically, liver metastases from colorectal carcinoma usually form as nodular tumor masses, whereas intraductal papillary growth in the bile duct is rare. A 65-year-old man underwent right hemicolectomy for advanced colon carcinoma, and histology of the primary carcinoma confirmed moderately differentiated adenocarcinoma with subserosal invasion, no vascular infiltration, and no lymph node metastasis. A liver tumor was found in the right paramedian Glisson pedicle and intraductal growth of cholangiocarcinoma was seen on imaging. We performed right hepatectomy and macroscopically, the resected specimen contained a growth in the bile duct lumen similar to cholangiocarcinoma. Histological examination revealed intraductal papillary proliferation of well-differentiated adenocarcinoma without vascular infiltration or lymph node metastasis in the hepatic hilum. Immunohistochemical staining revealed that the tumor cells were negative for cytokeratin-7 and positive for cytokeratin-20. Based on these findings, liver metastasis from colon carcinoma was diagnosed. Liver metastasis from colorectal carcinoma rarely arises as intraductal papillary growth in the bile duct, but the possibility of liver metastases with unusual morphology must be borne in mind for patients with a history of carcinoma in the digestive tract.     

胃肠肿瘤根治联合肝移植术治疗晚期胃肠肿瘤并肝脏广泛转移

目的 总结胃肠肿瘤根治联合肝移植治疗晚期胃肠肿瘤并发肝脏多发转移的近期疗效。方法 1例胃癌和2例直肠癌并发肝脏多发转移患者，分别接受胃癌和直肠癌根治、联合原位同种异体肝移植手术，其中1例因肺结核同时行左上肺部分切除术。结果 3例患者无围手术期死亡。随访5-7个月，胃癌患者术后5个月死于肿瘤复发；1例直肠癌并肺结核患者术后7个月死于肝功能衰竭，无肿瘤复发；另1例直肠癌患者已完成3个月化疗，术后半年无复发，肝功能和血常规正常，精神食欲好，已恢复工作。结论 胃肠肿瘤根治联合肝移植为部分晚期肿瘤患者提供了生存的希望，远期效果有待进一步观察。     

Adrenal Metastasis from Rectal Cancer: Report of a Case

We report a case of heterochronic adrenal metastasis from colorectal carcinoma in a 51-year-old woman. A left adrenal metastasis was found by computed tomography and magnetic resonance imaging 8 months after an anterior resection for advanced rectal carcinoma, and a left hepatectomy for a solitary liver metastasis. The level of serum carcinoembryonic antigen was still within the normal range. A left adrenalectomy was performed, and histopathological examination revealed adenocarcinoma, compatible with the rectal carcinoma resected 8 months earlier. The patient died of lung metastases 6 months after the adrenalectomy. A review of autopsy series in the world literature revealed that adrenal metastasis from colorectal cancer is not rare. Therefore, the possibility of adrenal metastasis should be considered in the follow-up of patients after primary surgery for colorectal cancer, even though the liver and lung are the main metastatic sites. Received: March 7, 2002 / Accepted: July 2, 2002 Reprint requests to: S. Murakami     

结直肠癌早期肝转移的预测

目的研究CK20 mRNA、CD44v6、血管内皮生长因子（VEGF）与结直肠癌肝转移的关系,探讨临床预测结直肠癌早期肝转移的有效的客观指标。方法应用荧光定量逆转录聚合酶链反应（RT—PCR）法检测50例结直肠癌患者回流门静脉血中CK20 mRNA,并同时应用免疫组织化学方法测定结直肠癌癌组织中CD44v6、VEGF的表达;并与良性病变对照组10例和正常组织对照组10例比较。结果结直肠癌患者门静脉血CK20 mRNA;癌组织中CD44v6、VEGF表达阳性率明显高于良性病变对照组（P〈0．01）和正常对照组（P〈0．01）;结直肠癌组织中CIM4v6及VEGF的表达与门静脉血中CK20 mRNA的表达有显著相关性（r．=0．933,r2=0．906,P〈0．05）;同时肝转移组CK20 mRNA、CD44v6、VEGF阳性表达率均高于非肝转移组（P〈0．05）。结论联合检测CD44v6、VEGF及CK20 mRNA预测结直肠癌肝转移,可提高预测的灵敏度及特异性,对于结直肠癌早期肝转移监测具有较高的临床价值。     

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.     

Evaluation of absolute non-curative resection in colorectal carcinoma

A total of 241 cases with colorectal carcinoma were treated surgically at our hospital in the past 8 years. Of these, the non-curative resection was performed in 62 cases (absolute non-curative resection in 54 and relative non-curative resection in 8). In this study 54 cases (27 colonic carcinoma and 27 rectal carcinoma) with absolute non-curative resection were evaluated from the aspect of pathologic findings and survival rate according to the non-curative factors (liver metastasis, peritoneal dissemination, lymph node metastasis and distant metastasis). Seventeen cases (63.0%) had two or more non-curative factors in the cases with colonic carcinoma and 21 cases (77.8%) one factor, especially liver metastasis, in the cases with rectal carcinoma. In the cases with rectal carcinoma, the invasion to the adjacent structures was recognized in 48.1%. The survival rates were correlated with the extent of the non-curative factors in the cases with absolute non-curative resection. However, longer survival would be expected, if the primary tumor could be resected, even in absolute non-curative resection for colorectal carcinoma.     

Small necrotic liver metastasis with microscopic tumor embolism in hepatic vein: a case report and review of the literature

Small liver metastasis of rectal carcinoma is mostly solid and rarely accompanied by necrosis. Microscopic invasion of the hepatic vein is rare in colorectal metastasis. A 53-year-old man, 2 years after rectal carcinoma resection, was noted to have a 15-mm liver tumor. On imaging, it was difficult to determine if the mass was hepatic abscess, cyst, solitary necrotic nodule, or liver metastasis. The resected tumor was metastatic liver cancer, the center of which had mostly atheromatous necrosis. Also, a microscopic tumor embolism was detected in the hepatic vein around the tumor. Liver tumors that grow should be suspected of being malignant and be resected.     

Treatment of colorectal liver metastasis with biliary and portal vein tumor thrombi by hepatopancreatoduodenectomy

We present a case of a large colorectal liver metastasis with portal vein and biliary tumor thrombi and duodenal and jejunal direct invasion that required hepatopancreatoduodenectomy. A 38-year-old woman presented to her local hospital with right back pain and jaundice. She had undergone transverse colectomy and limited liver resection for transverse colon cancer with a synchronous liver metastasis in September 1991, and low anterior resection for rectal carcinoma in January 1996. She was diagnosed as having colorectal liver metastasis and was referred to our hospital for possible surgery. Radiologic and endoscopic examinations revealed a large liver tumor occupying the right lobe, biliary dilation in the left lateral section, and a portal vein tumor thrombus. Invasion of the inferior vena cava and the right renal vein were also suspected. Intraoperative findings revealed a large liver tumor that occupied the right lobe and invaded the duodenum and jejunum. The tumor was resected successfully by right trisectionectomy, caudate lobectomy, pancreatoduodenectomy, partial resection of the jejunum, and combined portal vein resection and reconstruction. The inferior vena cava, right kidney, and renal vein could be detached from the tumor. The patient has enjoyed an active life without recurrence for 2 years since the operation.     

结直肠癌肝转移的危险因素分析

目的 探讨影响结直肠癌肝转移的危险因素.方法 回顾性分析1989年1月至2004年12月收治的1341例结直肠癌患者的临床资料.结果 1341例结直肠癌患者中有肝转移者155例,发生率为11.56%.性别、原发肿瘤部位和大小、区域淋巴结转移、肠壁浸润层次、邻近脏器侵犯、合并症和腹腔种植影响肝转移 (X2=6.517, 10.208, 11.173, 42.160, 80.731, 6.593, 3.887, 14.352, P<0.05).logistic回归分析显示,性别、区域淋巴结转移、肠壁浸润层次、合并症和原发肿瘤部位与结直肠癌肝转移有关 (b=0.655, -0.488, 1.355, -0.752,0.273, P<0.05).结论 男性、有区域淋巴结转移、肿瘤侵犯浆膜外组织的结直肠癌患者更容易发生肝转移;结肠癌较直肠癌更容易发生肝转移;有合并症的患者发生肝转移的几率小.     

Metabolic syndrome is an important factor for the evolution of prognosis of colorectal cancer: survival, recurrence, and liver metastasis

Background

Several studies have shown that metabolic syndrome (MS) was a risk factor for colorectal cancer, but few studies have reported the relationship between MS and the prognosis of colorectal cancer.

Methods

Data were collected from 507 cases of colorectal carcinoma between January 2002 and March 2007 to establish the database. These patients were divided into 2 groups based on the presence of MS. We tested the prognostic value of MS in the patients. The risk of adverse events was examined by Cox proportional hazard modeling.

Results

The rates of liver metastasis and tumor recurrence were higher in the group of patients with colorectal cancer accompanied by MS. Moreover, MS is one of the important elements that independently can influence the survival (colonic carcinoma: hazard ratio [HR], 1.633; 95% confidence interval [CI], 1.039-2.565; rectal carcinoma: HR, 1.939, 95% CI, 1.076-3.494) and liver metastasis (colonic carcinoma: HR, 2.619; 95% CI, 1.288-5.324; rectal carcinoma: HR, 2.814; 95% CI, .962-2.888) of both colonic and rectal carcinoma patients, and MS patients have the highest risk with worse survival and liver metastases compared with other parameters.

Conclusions

The results suggest that MS may be an important prognostic factor for colorectal cancer, decreasing the incidence of MS may improve the therapeutic efficacy of colorectal cancer.     

树突状细胞功能异常对结直肠癌肝转移的影响

目的 探讨树突状细胞(DC)功能异常对结直肠癌肝转移的影响及其意义.方法 收集2008年1月至2010年6月健康成年人30例、结直肠癌术前、术后无肝转移者30例和术后肝转移30例患者外周血,分离单核细胞后分别加入GM-CSF(1000 U/ml)、IL-4(1000 U/ml)和'TNF-α(1000 U/ml)诱导分化成熟DC,通过加入HT29大肠癌细胞抗原处理(100 μg/ml)或不处理,DC∶T细胞为1∶10,培养7 d,用ELISA方法测定培养液中IFN-γ和IL-10水平,酶标仪测定CCK8和LDH光密度(OD)值,间接测定T细胞增殖和杀伤能力.结果 结直肠癌术后肝转移患者外周血DC在无肿瘤抗原刺激时与健康人T细胞混合培养液IL-10水平显著低于结直肠癌术前患者和健康人[(11.9±1.3)pg/ml比(29.6±9.7)pg/ml、(23.4±8.0)pg/ml,F=4.475,P＜0.05].结直肠癌术后肝转移患者外周血DC经肿瘤抗原刺激与健康人T细胞混合培养液IFN-γ水平均显著高于结直肠癌术后和健康人[(34 ± 9)pg/ml比(26±12)pg/ml、(24 ±6) pg/ml,F=5.206,P＜0.05].结直肠癌术后肝转移患者DC经HT29肠癌细胞抗原刺激后诱导健康人T淋巴细胞杀伤能力显著高于结直肠癌术前患者和健康成年人[(30.6 ±8.6)pg/ml比(12.1 ± 2.4)pg/ml、(14.9 ±1.7)pg/ml,F=4.147,P＜0.05].结论 结直肠癌患者外周血DC在肿瘤抗原刺激下诱导T淋巴细胞产生IL-10,导致肿瘤免疫逃逸,发生肝转移;外源肿瘤抗原刺激能够提高T淋巴细胞杀伤能力.

Abstract：

Objective To observe the clinical significance and effect of dysfunction of dendritic cell( DC) in colorectal cancer with liver metastasis.Methods Peripheral blood were respectively collected from healthy adult donors (30 cases), preoperative and postoperative coloreatal cancer patients without liver metastasis (30 cases) , and 30 postoperative coloreatal cancer patients with liver metastasis from Jan 2008 to Jun 2010.Peripheral blood mononuclear cells were separated, GM-CSF( 1000 U/ml) , IL-4( 1000 U/ml) and TNF-α ( 1000 U /ml) were added into cell culture fluid to induce the mononuclear cells for mature dendritic cells.There were two subgroups, and in antigen processing subgroup the lysate of HT29 colonic carcinoma cells (100 μg/ml) were added into the cell culture fluid.The T lymphocytes from healthy adults were added into two subgroups by ratio of 1∶10 ( DCs∶ T cells) , cocultured for 7 days.The level of INF-γ and IL-10 in cell culture fluid was assayed with ELISA method.The optical density (OD) of CCK8 ans LDH was assayed with ELIASA to indirectly measure the reproductive activity and the killing efficacy of T lymphocytes.Results The IL-10 level in cocultured fluid of peripheral blood DCs in postoperative colorectal carcinoma patients with liver metastasis and T lymphocytes of healthy adults was significantly higher than that of preoperative patients of colorectal carcinoma and health adults without tumor antigenic stimulation(11.9±1.3) pg/ml vs.(29.6±9.7) pg/ml, (23.4±8.0) pg/ml, F =4.475, P ＜0.05).The IFN-γ level in cocultured fluid of peripheral blood DCs in postoperative colorectal carcinoma patients with liver metastasis and T lymphocytes of healthy adults was significantly higher than that of postoperative patients of colorectal carcinoma and healthy adults with or without tumor antigenic stimulation ( 34 ± 9) pg/ml vs.(26 ± 12 ) pg/ml, (24 ± 6) pg/ml, F = 5.206, P ＜ 0.05).The killing activity of healthy adults T lymphocytes induced by HT29 colonic carcinoma cells in postoperative colorectal carcinoma patients with liver metastasis was significantly higher than that of preoperative patients of colorectal carcinoma and healthy adults (30.6 ±8.6) pg/ml vs.(12.1 ±2.4) pg/ml, (14.9 ± 1.7) pg/ml, F =4.147, P ＜ 0.05).Conclusions T lymphocytes produce IL-10 when indued by DCs from patients with colorectal carcinoma under stimulation of tumor antigen leading to tumor immune escape and liver metastasis.The killing activity of T lymphocytes can be enhanced when stimulated by exogenous tmuor antigen.     

磁激活细胞分选技术用于结直肠癌外周血癌细胞富集的研究

目的：用磁激活细胞分选技术富集并定量分析结直肠癌患者外周血循环中的癌细胞。方法：术前抽取21例结直肠癌患者和9例对照者的外周血样，标记带磁珠的细胞角蛋白（Cytokeratin,CK)抗体，经磁柱富集CK＋上皮细胞，用流式细胞仪检测其含量。结果：在未经富集的标本中均未发现CK＋CD45－细胞。在经富集的标本中其含量在对照组与患者组间（P＜0．01），以及Dukes A-B期与Dukes C-D期患者间（P＜0．01）均差异有显著意义。结论：本方法能有效地富集上皮来源细胞；CD＋CD45－细胞能反映外周组织中肿瘤细胞情况，其与恶性肿瘤的存在，临床分期密切相关。     

大肠癌患者门静脉血癌细胞的检测及临床意义

目的 探讨门静脉血管癌细胞与大肠癌肝转移的关系。方法 以非核素ＲＴ－ＰＣＲ方法,对５４例大肠癌患者门静脉血中结肠癌细胞的标志物细胞角质蛋白２０（ＣＫ２０）进行了检测。结果 ５４例中,４１例门静脉血中检出ＣＫ２０阳性表达,阳性率７５．９％,ＣＫ２０阳性检出与Ｄｕｋｅｓ分期,肝转移存在显著性相关,随着Ｄｕｋｅｓ分期的进展ＣＫ２０阳性率显著增加,随访发现,门静脉血ＣＫ２０扩增阳性者,术后发生肝转移机会增     

结直肠癌发生部位与肝转移分布的关系

目的：初步探讨结直肠癌部位与肝转移分布之间的关系。方法：回顾性分析1984年1月至1997年7月间137例结直肠癌伴肝转移病人的资料。结果：52例右侧结肠癌的肝转移灶多位于右叶。另85例左侧结肠癌或直肠癌的肝转移灶分布在左叶、右叶或两叶无显著差异。结论：结直肠癌的部位可影响肝转移的分布，本文结果有助于结直肠癌肝转移部位的诊断，并为选择经肠系膜下静脉途径行门静脉化疗预防肝转移提供依据。     

c-Met在有、无肝转移结直肠癌组织中的表达差异

目的：探讨肝细胞生长因子受体（c-Met）在有、无肝转移结直肠癌组织中的表达及其临床意义。 方法：用real-time PCR法和Western-blot法分别对48例肝转移结直肠癌组织和48例无肝转移结直肠癌组织c-Met基因和蛋白表达进行检测,并分析c-Met的表达与各临床病理因素间的关系。 结果：肝转移结直肠癌组织中c-Met表达在mRNA和蛋白水平均明显高于无肝转移结直肠癌组织,差异均有统计学意义（均P<0.05）;c-Met的mRNA水平和蛋白水平均与临床分期、淋巴结转移密切相关（均P<0.05）,而与性别、年龄、组织分化程度及肿瘤部位无关（均P>0.05）。 结论：c-Met的高表达与结直肠癌肝转移有关,检测c-Met的表达对预测结直肠癌肝转移可能具有重要价值。     

Pancreatoduodenectomy after hepato-biliary resection for recurrent metastatic rectal carcinoma

Intrapancreatic bile duct metastasis from rectal carcinoma is rare. A 48-year-old man underwent extended left hepatic lobectomy and caudate lobectomy with extrahepatic bile duct resection for liver metastasis from a rectal carcinoma presenting with intrabiliary growth. A second recurrent tumor was successfully resected by pancreatoduodenectomy without injury to the jejunal loop for biliary reconstruction. Preservation of the previous bilio-enteric anastomosis was critical. Placing the jejunal limb of the hepaticojejunostomy through the retrogastric route was superior to placement through the common retrocolic and anteduodenal route, because the mesentery of the Roux-en Y jejunal limb did not obscure the pancreatic head. Histologic examination revealed a recurrent tumor growing into the remnant intrapancreatic bile duct. This suggested two possibilities: spontaneous shedding of cancer cells from the proximal metastasis, and implantation as a complication of percutaneous transhepatic biliary drainage. In both these circumstances, the metastatic lesion is not systemic, but is a local disease. An aggressive surgical approach for localized recurrence of this type may improve survival. Received: April 25, 2000 / Accepted: June 6, 2000     

Hepatic resection of giant metastatic tumor from clear cell carcinoma of the ovary

All cancer patients, particularly those treated for colorectal cancer, should be monitored for the presence of liver metastases, but liver metastases from ovarian clear cell carcinoma are quite rare. We report a patient subjected to extended left hepatectomy due to a giant metastasis 5 years after surgical treatment for an ovarian neoplasm that was histopathologically diagnosed as clear cell carcinoma. A 58-year-old woman had undergone hysterectomy and bilateral salpingo-oophorectomy due to ovarian cancer (stage Ic). Four years and 8 months after the operation, a computed tomography (CT) scan demonstrated a giant tumor in the left lobe of the liver. The tumor compressed the inferior vena cava (IVC), but it was not clear whether it invaded the vessel. She received chemotherapy for 4 months; however, the tumor did not decrease in size. She was subsequently referred to our institution and was submitted to operation after it was confirmed that there were no distant metastases. After being subjected to an extended left hepatectomy and cholecystectomy, the patient recovered from the surgery without any complications. She has been carefully followed for 17 months and has presented no evidence of recurrence.     

VEGF和微血管密度与大肠癌肝转移的关系

目的探讨血管内皮细胞生长因子（VEGF）和微血管密度（MVD）与大肠癌肝转移的关系。方法收集88例大肠癌患者的临床病理资料，检测VEGF血浆浓度、肿瘤组织含量，进行免疫组织化学染色，并计数微血管密度。结果血浆VEGF浓度与肝转移及TNM分期显著相关，肿瘤组织含量与肿瘤浸润深度、淋巴结转移、肝转移及TNM分期显著相关，VEGF染色阳性率与肝转移显著相关。VEGF和MVD正相关。术后肝转移患者的血浆VEGF浓度、肿瘤组织含量和染色阳性率以及MVD均显著高于无肝转移病例。结论VEGF和MVD与大肠癌的进展相关，是术后肝转移的预测指标。     

个体化治疗直肠癌同时性肝转移

肝转移是影响结直肠癌预后的重要因素之一。一般认为手术切除是唯一可能治愈结直肠癌肝转移的治疗手段。而近年随着新辅助化疗与肿瘤物理消融技术以及微创技术的进展,尤其在生物一心理一社会的现代医学模式背景下,对可以手术切除的结直肠癌同时性肝转移患者如何选择更为合理的手术方式尚存在较多争议。中国医科大学附属盛京医院收治1例直肠癌同时性肝转移患者经新辅助化疗后腹腔镜下肝转移癌微波消融＋开腹结直肠癌根治性切除术的联合序贯治疗,为同类患者治疗方式的个体化选择提供参考。     

Laparoscopic resection of colon cancer and synchronous liver metastasis

The recommended surgical approach to synchronous colorectal metastasis has not been clarified. Simultaneous open liver and colon resection for synchronous colorectal carcinoma has been shown beneficial when compared to staged resections. A review of the literature has shown the benefits of both laparoscopic colon resection for colorectal cancer and laparoscopic left lateral segmentectomy in liver disease. We present the case of a 60-year-old male with sigmoid colon carcinoma and a synchronous solitary liver metastasis localized to the left lateral segment. Using laparoscopic techniques, we were able to achieve simultaneous resection of the sigmoid colon and left lateral liver segment.