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An Unusual Metastatic Pattern of a Transverse Colon Cancer: A Case Report and Review of Literature
Tallat Ejaz1*, Shahbaz Mansoor1,2 and Eltaib Saad1
1Department of Surgery, Midland Regional Hospital Mullingar, Mullingar, Co-Westmeath, Republic of Ireland
2Honorary Clinical Associate Professor, Maastricht University and Royal College of Surgeons in Ireland (RCSI) - Dublin
Submission: January 01, 2019;Published: January 31, 2019
*Corresponding author: Tallat Ejaz FRCSI, General and Pediatric Surgeon, Midland Regional Hospital Mullingar
How to cite this article: Tallat E, Shahbaz M, Eltaib S. An Unusual Metastatic Pattern of a Transverse Colon Cancer: A Case Report and Review of
Literature. Open Access J Surg. 2019; 10(2): 555785. DOI: 10.19080/OAJS.2019.10.555785.
Colorectal cancer is the second most common cancer in females and the third in males worldwide. The most common sites of colorectal cancer metastasis are the liver, lungs, peritoneum, brain, and bones. Metastasis to para-aortic, mediastinal and left supraclavicular lymph nodes without visceral involvement is fairly rare. We present a rare case of a transverse colon cancer in a young patient with an unusual metastatic pattern to para-aortic, anterior mediastinal and left supraclavicular nodes without hepatic, pulmonary or bony metastasis. The patient’s main complaint was a left supraclavicular swelling for 3 months. Notably, he had no specific symptoms to suggest colonic tumor. Left supraclavicular node biopsy revealed metastatic glandular tumor with a likely primary colorectal origin. A colonoscopy showed a mass at the proximal transverse colon and CT scan of the chest, abdomen and pelvis revealed a locally advanced transverse colon tumor with involved regional nodes and a distant metastasis in para-aortic, anterior mediastinal and left supraclavicular lymph nodes. No liver, lungs or bone metastasis noted. He underwent an extended right hemicolectomy and was referred to oncology team for palliative chemotherapy.
a. Left supraclavicular lymphadenopathy can be the first manifestation of an advanced colonic cancer, even in absence of typical clinical features of colonic cancers.
b. Systemic metastasis of a colonic tumor to para-aortic, anterior mediastinal and left supraclavicular lymph nodes without solid visceral (the liver, lungs and bones) involvement is a rare oncological entity but may occur as demonstrated in this case.
Colorectal cancer (CRC) is the second most common cancer in females and the third in males worldwide . The literature reported a steady increase in the incidence of CRC among both males and females under the age of 50 at a rate of 2.1% per year from 1992 through 2012 . Nevertheless, screening is not currently recommended for individuals under the age of 50 unless they have inflammatory bowel disease, a positive family history, or a predisposing inherited syndrome . CRCs spread principally through lymphatic and hematogenous routes, and less commonly by contiguous and trans-peritoneal dissemination . Approximately 20% of patients in the United States have a distant metastatic disease at the time of presentation . The
most common reported metastatic sites are the liver, lungs, brain, peritoneum, and bones . Most CRCs (60%) eventually develop metastatic disease, with liver involvement alone accounts for almost 50% of systemic metastasis .
Metastasis to mediastinal and left supraclavicular lymph nodes without solid organs involvement is a fairly rare oncological entity [5-9]. We present a rare case of a transverse colon cancer in a young patient with an unusual pattern of metastasis to para-aortic, anterior mediastinal and left supraclavicular lymph nodes without solid organs (liver, lungs and bones) metastasis. The patient’s chief complaints were a left supraclavicular swelling and weight loss for 3 months. Interestingly, he didn’t report any abdominal pain, recent bowel habits changes, rectal bleeding or anemia symptoms. A few reports in the reviewed literature described the similar pattern observed in this presented case [6-9].
A 45-year-old Caucasian male was referred to our clinic with a 3-month history of left supraclavicular swelling and unintentional weight loss. His past medical history was significant for gastritis 7 years ago which was responsive to proton pump inhibitors (PPI) courses. He had no voice changes, epistaxis, difficulty or pain during swallowing, epigastric pain, nausea or vomiting. He didn’t have abdominal pain, recent bowel
habits changes, or rectal bleeding. Additionally, he had no cough,
chest pain, haemoptysis or shortness of breath. The patient also
denied fever, chills, night sweating, rash, pruritus or bruising.
The rest of the systemic review was otherwise unremarkable.
His family history was significant for gastric cancer. He was a
social drinker, but he never smoked.
Physical examination was significant for an enlarged (4X4)
cm firm and fixed left supraclavicular lymph node (Troisier’s
sign). Cervical, axillary and inguinal lymph nodes were not
clinically palpable. Abdominal examination revealed a soft
and non-tender abdomen with no palpable masses. There was
no hepatomegaly or splenomegaly. The rest of the systemic
was essentially normal. General blood tests revealed a low Hb
(10.5 g/dl) with normal total and differential WCC and platelets
counts. Renal and liver profiles were within the normal ranges.
His CXR was normal. He underwent a left supraclavicular lymph
node biopsy under anesthesia. Histological examination of node
tissues showed a metastatic poorly-differentiated malignant
tumor with glandular components (Figure 1).
Immunohistochemistry revealed a strong positivity for AE1/
AE3 and Cytokeratin 20 (CK20), and PASD stained for mucin,
but the staining for Cytokeratin 7 (CK7), p63, and TTF-1 was
negative. The findings suggested a likely primary colorectal
origin. He underwent an urgent OGD and full colonoscopy.
OGD revealed a normal esophageal mucosa and mild gastritis
which tested negative for H. pylori. Full colonoscopy detected
a partially-obstructing circumferential mass at the proximal
transverse colon near the hepatic flexure. The biopsy report from
this colonic mass confirmed an invasive poorly-differentiated
colonic adenocarcinoma and the findings were almost identical
to the left supraclavicular node’s biopsy. The patient had a
computed tomography (CT) scan of the chest, abdomen and
pelvis which depicted a locally advanced proximal transverse
colon tumor spreading well beyond the serosa posteriorly with
local infiltration of pericolic fat and regional lymphadenopathy
Figure 2-A. There was a significant metastasis in the para-aortic
nodes Figure 2-B, anterior mediastinal nodes Figure 2-C and
left supraclavicular nodes Figure 2-D. No evidence of hepatic,
pulmonary or bony metastasis noted. Carcinoembryonic antigen
(CEA) level was above the normal (22 ng/ml, normal reference
<3.5 ng/ml). Alpha-fetoprotein (AFP) level was within the
A multidisciplinary team (MDT) meeting advised for a
tumor resection as the patient was at a high risk of a large bowel
obstruction, and a palliative chemotherapy for the advanced
metastatic disease. He underwent a laparoscopic-assisted
extended right hemicolectomy with an uneventful perioperative
course. Histopathology of the surgical specimen revealed a
poorly-differentiated transverse colon adenocarcinoma Figure
3A-3B with a full-thickness invasion of the bowel wall and extensive infiltration of pericolic fat. 2 out of 20 lymph nodes
examined were positive with extensive lympho-vascular
invasion and positive mesenteric margins. The staging was
stage IV (T4N1M1). KRAS assay returned wild. He was referred
to the oncology team for palliative chemotherapy. The patient
was treated with cycles of XELOX regimen (capecitabine plus
oxaliplatin) with Erbitux (cetuximab, C225). Initial follow-up CT
scans of the neck, chest and abdomen after 4 months revealed a
positive response to chemotherapy with acceptable diminution
of the mediastinal and para-aortic lymph nodes, but a stable left
supraclavicular node status. The patient was alive for 2 years
following the extended right hemicolectomy.
Despite increasing uptake of CRC through screening
programs to detect asymptomatic stage, most CRCs (70 to 90
% in recent series) are diagnosed after the onset of symptoms
. The symptoms of colonic tumors would vary according
to the location and the size of the primary tumor. Right-sided
carcinomas are usually polypoid or ulcerative lesions that
present with abdominal pain (60%), chronic blood loss (48.5%),
anemia (21.3%), abdominal mass (24.%) or obstruction if they
occlude the lumen (17%), while left-sided carcinomas are
commonly obstructive rings that present with bowel habits
changes (48%), diarrhea (12%) or large bowel obstruction .
In addition, non-specific symptoms, for instance, weight loss
and anorexia occur in less than one-third of patients (28.8%).
Additionally, about 2.5% of patients are asymptomatic at the
time of diagnosis . Interestingly enough, our patient had no
specific symptoms to suggest a colonic tumor, although the tumor
had resulted in a remarkable narrowing of the lumen near the
hepatic flexure as noted on CT scan findings, and he was at a high
risk of a large bowel obstruction. Almost 20% of CRC patients in
the United States would have a distant metastatic disease at the
initial time of presentation . The liver, lungs, peritoneum, brain,
and bones are the most frequently reported extra-abdominal
metastatic sites [2,4], with the liver involvement alone accounts
for almost 50% of systemic metastasis  and nearly 85% in
other series of 89 patients with metastatic (stage IV) disease
. The metastatic pattern observed in this case without liver
or lungs involvement thus represents an oncological rarity.
Distal metastasis of colorectal tumors to mediastinal lymph
nodes without lung metastasis is an exceedingly rare entity [5,12-
15]. In fact, Kousa et al. mentioned only 7 cases of metachronous
mediastinal lymph node metastasis from colorectal cancers in the
English literature, including his reported one . Nevertheless,
the exact route of mediastinal lymph node metastasis with colon
cancers is not yet known [5,13,15]. It has been postulated that
involvement of the mediastinal lymph nodes is through the
para-aortic lymphatic drainage route towards the thoracic duct
. This presumed theory might explain the metastasis to the
posterior mediastinal nodes group due to their close proximity
to (and their eventual drainage) to the thoracic duct, but would
not justify the involvement of the anterior mediastinal lymph nodes group (as occurred in our patient), which are however,
well-distant from the thoracic duct and they don’t usually drain
to it as there is no direct communication between the thoracic
duct and Broncho mediastinal trunk that drain these lymph
nodes group .
Nevertheless, MacLoud et al.  suggested a retrograde
reflux of tumor micro-emboli from the thoracic duct into the
Broncho mediastinal trunk through incompetent lymphatics
valves and this would possibly explain the anterior mediastinal
lymph nodes involvement. Cervical and left supraclavicular
lymphadenopathy is well-known to be the first manifestation of
colorectal tumors [6,7]. Nevertheless, the occurrence of distant
cervical and supraclavicular nodes metastasis without solid
organs metastasis is typically rare and was reported only in a
few cases in the reviewed literature [6-9]. It has been suggested
that after the metastatic involvement of para-aortic lymph
nodes, a sequential left supraclavicular metastasis occurs as a
result of infiltration of the thoracic duct with tumor cells with
formation of skip metastasis between the regional lymph node
stations and the distal nodes which are considered as end-nodes
of the lymphatic pathway .
We report an unusual metastatic pattern of a transverse
colonic tumor to the anterior mediastinal and supraclavicular
lymph nodes without liver or lungs involvement. In this reported
case, the patient’s main complaint was a left supraclavicular
swelling and he had no colonic cancer-suggesting symptoms,
though the tumor had caused a remarkable luminal narrowing
with extensive local invasion as noted on CT scan findings. This
case also demonstrates the clinical significance of enlarged left
supraclavicular node (Virchow’s node) which denotes a distant
metastasis from aero-digestive malignancies; a critical finding
that should warrant an urgent work-up to search for the primary