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Colon Biopsy
Colonoscopic biopsies of thickened anastomosis contain low grade dysplasia/adenomatous change. -
Presents to ED
Presents to Emergency Department with proctalgia and hematochezia after restarting Plavix for another cardiac stent. CT abdomen/pelvis demonstrates new 1.2 cm lesion in right liver and worsened anastomotic thickening with mesenteric lymphadenopathy. -
Colon Biopsy
Colonoscopic biopsies of ulceration 30 cm from anal verge reveals small cell carcinoma. -
PET/CT
PET/CT shows metastasis to the right liver and lymph nodes in the distribution of the left colon/inferior mesenteric artery stump. Chest negative. -
Liver Biopsy
Needle core biopsy of right liver lesion demonstrates metastatic small cell carcinoma. -
Neoadjuvant Chemo Starts
Starts neoadjuvant chemotherapy with Carboplatin/Etoposide. -
Presents to Mayo Clinic
Presents to the Mayo Clinic for multidisciplinary consultation. CEA is 2.9. CA19-9 is 35. -
MRI
MRI Abdomen demonstrates 13 mm metastasis in liver segment VIII and 5 mm lesions in segment VI and IV. -
Chemo Change
After 2 cycles of initial regimen, switched to Cisplatin/Etoposide -
Interval CT
After 2 cycles on new regimen (4 cycles total), CT chest/abdomen/pelvis demonstrates decrease in size of liver lesion to 0.8 cm and improved paracolonic adenopathy. -
Neoadjuvant Chemo Completed
6 cycles of chemotherapy completed. -
Post-chemo MRI
MRI abdomen shows interval decrease in size of segment VIII liver metastatic lesion. Previously identified indeterminate lesions indiscernible. Liver remnant volumetrics = 21%. -
Portal Vein Embolization
Right portal vein embolized. -
Pre-Operative MRI
MRI abdomen shows indiscernible hepatic metastases. Liver remnant volumetrics = 35%. -
Operation
Cystoscopy and bilateral ureteral stenting, right extended hepatectomy, intraoperative ultrasound, round ligament pedicle flap, cholecystectomy, proctocolectomy with abdominoperineal resection and periaortic lymphadenectomy. Pathology reveals pT3pN2apM1a adenocarcinoma and high grade neuroendocrine carcinoma. -
POD#3
Patient transferred from ICU to floor. -
POD#5
NGT placed for ileus. -
POD#10
Ostomy function. NGT removed, and diet advanced. -
POD#11
Duplex ultrasound for edema identified RLE DVT. Anticoagulation started. -
Discharged home
POD#15 patient discharged home. -
Clinic Follow-up
POD#35: Transplant POV and Oncology follow-up visit. Decision not to pursue adjuvant chemotherapy until recurrence. -
Recurrence
MRI demonstrates hypoenhancing nodular lesion in remnant liver not adjacent to resection margin, posterior to middle hepatic vein and 2 subcentimeter areas of diffusion restriction in lateral segment of left lobe that are not visible on the postcontrast images and therefore of uncertain significance. -
Liver Biopsy
Liver biopsy positive for metastatic small cell carcinoma -
Recommendations
Oncology would recommend off-label use of Nivolumab for small cell carcinoma. Patient unable to continue care at Mayo due to insurance.