Abstract
BackgroundDistant metastases from colon cancer spread most frequently to the liver and the lung. Risk factors include positive lymph nodes and high grade tumors. Isolated metastases to the appendicular skeleton are very rare, particularly in the absence of identifiable risk factors.Case reportThe patient was a 55 year old male with no previous personal or family history of colon cancer. Routine screening revealed a sigmoid adenocarcinoma. He underwent resection with primary anastomosis and was found to have Stage IIA colon cancer. He declined chemotherapy as part of a clinical trial, and eight months later was found to have an isolated metastasis in his right scapula. This was treated medically, but grew to 12 × 15 cm. The patient underwent a curative forequarter amputation and is now more than four years from his original colon surgery.DiscussionStage IIA colon cancers are associated with a high five year survival rate, and chemotherapy is not automatically given. If metastases occur, they are likely to arise from local recurrence or follow lymphatic dissemination to the liver or lungs. Isolated skeletal metastases are quite rare and are usually confined to the axial skeleton. To our knowledge, this is the first reported case of an isolated scapular metastasis in a patient with node negative disease. The decision to treat the recurrence with radiation and chemotherapy did not reduce the tumor, and a forequarter amputation was eventually required.ConclusionThis case highlights the importance of adequately analyzing the stage of colon cancer and offering appropriate treatment. Equally important is the early involvement of a surgeon in discussing the timing of the treatment for recurrence. Perhaps if the patient had received chemotherapy or earlier resection, he could have been spared the forequarter amputation. The physician must also be aware of the remote possibility of an unusual presentation of metastasis in order to pursue timely work up.
Highlights
Distant metastases from colon cancer spread most frequently to the liver and the lung
This case highlights the importance of adequately analyzing the stage of colon cancer and offering appropriate treatment
The physician must be aware of the remote possibility of an unusual presentation of metastasis in order to pursue timely work up
Summary
Colorectal cancer is the third most common cause of cancer in men and women in the United States [1]. Screening for colon cancer is an important factor in decreasing the morbidity and mortality of the disease, given the much higher survival rate for earlier stage tumors versus more advanced disease. The NCCN identified several risk factors that may help determine which patients would benefit most from the addition of chemotherapy These include high grade tumor characteristics on histology, perforation or obstruction at the time of presentation, lymphovascular invasion, or fewer than 12 lymph nodes removed during resection. Our technique consisted of a combined anterior and posterior approach as described by Ferrario et al [14], allowing complete dissection of bone and soft tissue prior to transection of the subclavian vessels This approach provides circumferential access to the vessels and brachial plexus prior to ligation and significantly reduces the risk of uncontrolled bleeding as well as allowing for a greater proximal margin. While advances have been made in approaching the reconstruction of irradiated tissues [19,20], chest wall resection and reconstruction (if necessary) would have been much simpler prior to receiving radiation
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