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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 4 (2013) 1017– 1020

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

jou rna l h omepage: www.caserepor ts .com

plenic metastases from caecal carcinoma: Diagnostic considerationsnd therapeutic strategy

.P. Burkea, P.S. Watersa, J. Hanaghanb, F. Bennanic, W. Khana, K. Barrya,∗

Department of Surgery, Mayo General Hospital, Mayo, IrelandDepartment of Radiology, Mayo General Hospital, Mayo, IrelandDepartment of Pathology, Mayo General Hospital, Mayo, Ireland

r t i c l e i n f o

rticle history:eceived 28 August 2013ccepted 3 September 2013vailable online 9 September 2013

eywords:aecal adenocarcinomaplenic metastasesmage guided biopsyarcinoembryonic antigen

a b s t r a c t

INTRODUCTION: The spleen is a highly vascular organ and is in close proximity to many potential primarysites such as the stomach, breast, pancreas and colon. It is however an unusual site for metastatic disease.The reasons for this are not fully understood at the present time. A number of hypotheses have beenpostulated. Definitive diagnosis and subsequent treatment of metastatic disease to the spleen presentsa number of challenges for the surgeon and the wider multi disciplinary team.PRESENTATION OF CASE: A 60 year old male presented with a three week history of lower abdominal pain,distension, nausea and a palpable mass in the right iliac fossa. Imaging revealed a large circumferentialcaecal mass consistent with malignancy with secondary small bowel obstruction. The patient underwentan emergency right hemicolectomy and was subsequently treated with systemic chemotherapy for lymphnode positive caecal adenocarcinoma. Two years following initial presentation, two suspicious lesionswere noted within the spleen during routine surveillance imaging with computerised tomography ofthe thorax, abdomen and pelvis. Of note, one month prior to this the patient had a normal surveillancecolonoscopy performed with multiple interval carcinoembryonic antigen (CEA) levels recorded within

the normal range. Image guided splenic biopsy and subsequent histology confirmed metastatic caecaladenocarcinoma.DISCUSSION: Splenic metastases from any source including the colon are a rare phenomenon.CONCLUSION: This case questions the value of routine post operative CEA monitoring, underlines theimportance of multimodal pathways of surveillance and highlights recent advances in image guided

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splenic biopsy technique© 2

. Introduction

Metastases to the spleen from various sites are a rare occur-ence and usually occur in the presence of widely disseminatedisease.1 Previously documented sites of primary disease includehe ovaries, melanoma, breast, lung and the colon and are typicallyssociated with high disease burden. Splenic metastases from theolon involving low levels of disease burden are rare in the liter-ture and to date, there have been only two documented cases ofetastases to the spleen originating from a caecal tumour2,3.

. Case report

A 60 year old male with no significant past medical history pre-ented to the emergency department with a three week history of

∗ Corresponding author. Tel.: +353 94 9028044.E-mail address: kbarsurg@eircom.net (K. Barry).

210-2612 © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associate ttp://dx.doi.org/10.1016/j.ijscr.2013.09.002

he Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

lower abdominal pain, nausea and a palpable mass in the right iliacfossa. Computerised tomography (CT) of the abdomen and pelvisdemonstrated a large circumferential obstructing tumour of thecaecum without evidence of distant metastases (Fig. 1). The patientwas prepared for surgery, consisting of a right hemicolectomy withan uncomplicated postoperative course. Histology from the excisedspecimen revealed a poorly differentiated adenocarcinoma withsignet ring cell permeation through the muscularis propria. Lymphnode analysis comprised twenty one lymph nodes, all noted tocontain metastatic spread. Additional CT of thorax performed inthe post operative period was reported as normal. The presentingtumour was therefore classified pathologically as stage III caecaladenocarcinoma (pT3N2M0). Carcinoembryonic antigen measuredprior to surgery was recorded within normal limits (3 ng/L).

Two months post surgical resection, the patient underwentadjuvant chemotherapy utilising the FOLFOX protocol as dis-cussed at the multidisciplinary conference. He received 12 cycles of

Open access under CC BY-NC-ND license.

chemotherapy however the dose of oxaliplatin was reduced aftercycle six due to development of thrombocytopaenia and a slight risein CEA level, both of which were attributed to the chemotherapeuticagent (Table 1). He completed his course of adjuvant chemother-apy eight months after initial presentation. The patient was then

s Ltd. Open access under CC BY-NC-ND license.

CASE REPORT – O1018 T.P. Burke et al. / International Journal of Surg

Fig. 1. CT image at presentation demonstrating a large caecal neoplasm with con-current small bowel obstruction.

Table 1Surveillance.

Test Result (ng/ml)

CEA June 2011 3CEA October 2011 6CEA November 2011 5.2CEA January 2012 5.7Restaging CT May 2012 No evidence of metastatic diseaseCEA May 2012 2.4

eslArt

In most of the reported cases of colorectal metastases to the

Colonoscopy NormalFollow up CT May 2013 Two splenic lesions

ntered into a standard programme of routine surveillance con-isting of regular clinical reviews, interval measurement of CEAevels, colonoscopy and yearly CT of thorax, abdomen and pelvis.

lthough surveillance studies proved negative initially for diseaseecurrence, a routine CT thorax, abdomen and pelvis at twentyhree months post initial presentation revealed left sided para

Fig. 2. Surveillence CT demostrating a normal CT in May 2012

PEN ACCESSery Case Reports 4 (2013) 1017– 1020

aortic lymphadenopathy and two suspicious splenic lesions mea-suring 2.7 × 2.5 cm and 2.4 × 2.2 cm respectively which were notpresent on imaging, performed twelve months previously (Fig. 2 Aand B). The patient was completely asymptomatic at the time ofmetastatic presentation.

The splenic lesions were biopsied under ultrasound guidanceusing an 18 gauge tru cut needle without complication (Fig. 3). Sub-sequent histology of the biopsied lesions revealed normal splenicparenchyma infiltrated by poorly differentiated adenocarcinomawith abundant signet ring cells, morphologically identical to theinitial presentation with an obstructing caecal tumour (Fig. 3C).Further discussion at the multidisciplinary conference ensued. Thedisease although of low burden and primarily localised to thespleen was associated with the presence of suspicious para aorticlymphadenopathy prompting chemotherapy rather than opera-tive intervention. The oncology team advised further systemicchemotherapy comprising 5 – fluorouracil, oxaliplatin and avastin.The patient remains well on chemotherapy and further imagingstudies are planned in 4 months time to assess response to treat-ment.

3. Discussion

Metastases to the spleen from any primary tumour are raredespite the highly vascular nature of the organ and it’s proximity tomany potential primary sites including the pancreas, stomach, lung,breast and the colon. A number of theories have been put forwardto explain the “hostile” nature of the spleen preventing tumourimplantation and proliferation of neoplastic cells. These encom-pass intrinsic anatomical, histological and immunological featuresof the spleen.4,5 Anatomical features thought to play a role includethe sharp angle at the origin of the splenic artery with the coeliacaxis, the rhythmic contraction of splenic sinusoids and the scarcityof lymphatic vessels extending to the intrasplenic parenchyma.Immunological factors considered to negatively impact on the rateof malignant cell implantation include the presence of abundantkupffer cells, immunoglobin synthesis and opsonin production.

spleen, the primary tumour is located on the left side of the colonor in the rectum.6 This distribution of colorectal metastases favoursthe theory that neoplastic cells reach the spleen via retrograde

and abnormal CT with two splenic lesions 1 year later.

CASE REPORT – OPEN ACCESST.P. Burke et al. / International Journal of Surgery Case Reports 4 (2013) 1017– 1020 1019

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ig. 3. US biopsy of splenic lesion demostrating biopsy needle through the metasisease.

issemination through the inferior mesenteric vein.7 To the best ofur knowledge, there have been only two previous cases of caecaldenocarcinoma metastasising to the spleen recorded in the litera-ure without infiltration of other solid organs.2,3 Furthermore, thereave only been 4 additional cases of right sided colonic cancer (allscending colon) with metastases to the spleen recorded.6 Givenhe additional presence of left sided para aortic lymphadenopathyn our patient, this could possibly indicate tumour spread via theymphatic system.

Carcinoemryonic antigen (CEA) is an oncofoetal protein useds a tumour marker. It is not routinely used as a screening tools it lacks sensitivity and specificity. However it is widely useds part of surveillance programmes to monitor for disease recur-ence in conjunction with colonoscopy, imaging and follow uplinic appointments. It has been shown that in 30–40% of casesf disease recurrence there is no corresponding rise in CEA levels.8

urthermore in cases where CEA levels were recorded as normal atnitial presentation, it was reported that in cases of recurrence, aorresponding elevation in CEA is only observed in 27% of cases.9 Inne large study, it was noted that CEA monitoring did not result inmproved survival.10 This brings into question the value of intervalEA monitoring as part of surveillance programmes post resectionor colorectal cancers.

Historically the technique of percutaneous splenic biopsy wasot widely performed due to the perceived high complication ratesostly involving haemorrhage. With the advent of improved imag-

ng modalities, splenic biopsies can now be performed relativelyafely using either ultrasound or CT guided techniques. Ultrasounds currently favoured over CT due to the real time images projected.he differential of a solid splenic lesion includes metastases, annfarct or a splenic abscess. Adequate collection of targeted tissueuitable for histological analysis has been recorded at 88% in oneeries. Complication rates were found to be directly proportional

o the gauge of needle used in the procedure.11

Given the limited number of cases recorded in the literature,he optimal treatment for splenic metastases from a colorectal pri-

ary is not known. In cases of isolated splenic metastases from a

deposit and the histology slide displaying histological confirmation of metastatic

colonic source, splenectomy is preferred to chemo/radio therapy.In the literature, this has been performed by both the traditionalopen technique and more recently laparoscopically.12 To date dis-ease free intervals and survival are reported to be similar for bothtechniques. Chemotherapy is currently favoured in circumstanceswhere disease is recorded in other sites including the spleen. Thecurrent data available is too small to draw any definitive conclu-sions regarding the optimal treatment for splenic metastases in thecontext of low disease burden.

4. Conclusion

This case illustrates a number of important features regardingsplenic metastates from caecal carcinoma. Firstly, multimodalimaging is important in the context of asymptomatic patients andespecially given the limited sensitivity of CEA meaurements. Sec-ond, modern image guided biopsy techniques facilitate accurateand safe percutaneous biopsy of suspicious splenic lesions. Third,further research is necessary to determine the optimal treatmentof splenic metastases from a colonic source with a low diseaseburden.

Conflict of interest statement

None declared.

Funding

None.

Ethical approval

Written informed consent was obtained from the patient forpublication of this case report and accompanying images. A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request.

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CASE REPORT020 T.P. Burke et al. / International Journal o

uthor contributions

Thomas Patrick Burke is the Primary author of the Paper. Peadaraters helped in the review of article and compiling of images.

ohn Hanaghan helped in the review of Radiology of the case. Fadelenani helped in the review of pathology. Waqar Khan helped

n the review of case and literature. Kevin Barry helped in thenal review of article prior to submission including editing and

ayout.

cknowledgments

None.

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