T1 Colorectal Cancer with Synchronous Liver Metastasis
The patient was a 68-year-old Japanese man who was admitted to our hospital with a liver tumor that had been detected by abdominal ultrasonography. His medical history included hypertension, diabetes mellitus and gout. Physical examination indicated no significant findings. Laboratory tests showed: erythrocyte count 484 × 104/mm3 (normal 420–554), hemoglobin 15.9 g/dl (normal 13.8–16.6), leukocyte count 8,600/mm3 (normal 3,500–9,000), platelet count 21.8 × 104/mm3 (normal 15.5–36.5), serum total protein 6.5 g/dl (normal 6.3–8.1), total bilirubin 0.69 mg/dl (normal 0.3–1.2), aspartate aminotransferase 28 IU/l (normal 9–38), alanine aminotransferase 27 IU/l (normal 4–36), alkaline phosphatase 224 IU/l (normal 115–359), γ-glutamyl transpeptidase 53 IU/l (normal 4–68), blood urea nitrogen 16 mg/dl (normal 9–21), and creatinine 0.92 mg/dl (normal 0.60–1.20). Hepatitis B surface and hepatitis C antibody were negative. Carcinoembryonic antigen and CA19-9 were both elevated at 23.9 ng/ml (normal 0–3) and 51 U/ml (normal 0–37), respectively.\nAbdominal ultrasonography revealed a hyperechoic mass in segment 7 of the liver, 30 mm in diameter, with a circumferential hypoechoic area. Abdominal computed tomography also showed mild enhancement of a liver tumor 30 mm in diameter at the portal phase (fig. ). On colonoscopy, a pedunculated tumor with a central depression (20 mm in diameter) was observed in the ascending colon, and this tumor was considered to be invading deeply into the submucosal layer (fig. ). Abdominal magnetic resonance imaging showed the liver tumor as a low-intensity mass in the T1 emphasis phase (fig. ), as a high-intensity mass in the T2 emphasis phase (fig. ) and as a strongly high-intensity mass by administering the contrast medium ferumoxide (fig. ). T1 colorectal carcinoma with liver metastasis was suspected, and right hemicolectomy with D3 lymphadenectomy and partial hepatectomy were performed simultaneously (fig. ). On histopathological examination of the resected specimen, the tumor was a well-differentiated tubular adenocarcinoma with 3,000 μm invasion of the submucosal layer (fig. ) and venous permeation without tumor budding or lymph node metastasis. The liver tumor showed histological findings similar to those of the primary colorectal carcinoma (fig. ). The pathological stage according to the 7th edition of the TNM classification was stage IV (T1N0M1). The patient had an uneventful postoperative course. He took 5-FU drugs orally for 6 months as a postoperative adjuvant chemotherapy. Nine months after the operation, elevation of serum carcinoembryonic antigen was recognized. Computed tomography revealed hepatic hilar lymph node metastases and a great deal of ascites. His general condition worsened, and the patient ultimately died 14 months after the operation.