Secondary Malignancy in mesentery

Secondary Malignancy in mesentery following primary rectal cancer with multiple colonic polyps
Short Summary

69-year-old male found on colonoscopy to have multiple polyps and a rectal cancer. He underwent preoperative chemoRT, underwent resection and received a single cycle of bolus 5-FU with leucovorin. In early 2007, he had multiple complications and ultimately has a permanent ileostomy. Scans over the next few years have demonstrated nonspecific findings in his thorax however in July 2008 he had a mesenteric mass with adenopathy. These lesions had FDG uptake on PET scan.

Patient's Questions
Advice is needed concerning the possibilities for further treatment. He has been advised that surgery is not an option. 
 
Medical Background

Male, 69
Diagnosis: Secondary Malignancy in mesentery (PET/CT- Aug 2008), following primary rectal cancer with multiple colonic polyps (Oct 2005)

Below is the medical summary.
According to the PET/CT there appears to be localized metastasis in the mesentery with lymph node involvement, occurring 3 years after initial diagnosis of rectal carcinoma with multiple colon polyps.
The patient has a high output ileostomy, mild renal failure (creatinine clearance 66L/MIN). After total colectomy Feb 2006 had to stop 5FU/LV 600mg m2/500mg/m2 weekly because of grade 4 diarrhea. The Israeli surgeon Prof X examined patient and PET/CT and said surgery is not an option in this case (lymph node involvement?).
 
Medical Summary
 
This 69 year patient, married with three children. He was entirely well until his present illness. There is no relevant family history and he was asymptomatic. In May 2005 he had 1/3 positive Hemoccult test and colonoscopy was performed in October 2005. A semicircular tumor 3-8 cm from the dentate line was found and biopsied. In addition, there were at least 10 colonic polyps of various sizes. The two largest were in the ascending colon, sessile, 2.5 cm in diameter and suspicious for malignancy and another polyp 1.5 cm in diameter 85 cm from the anus. The remaining polyps were 1 cm in diameter or less and were removed. The main findings based on the histology report were:
1.    A large rectal tumor – well differentiated adenocarcinoma
2.    Polyp at 85 cm – biopsies showed a tubulovillous adenoma and focus of high grade dysplasia
3.    Ascending colon – tubulovillous adenoma with foci of high grade dysplasia
10.05 CT of the chest and abdomen showed no evidence of metastases
10.05 Endoscopic ultrasound of the rectum showed that the tumor was T3N0
11.08 PET-CT FDG concentration in the rectal tumor and the ascending colon. No absorption in lymph nodes.
Blood tests including liver enzymes were normal. CEA and other tumor markers have been consistently normal
 
A Port-a-cath was inserted on11.05 and he began neoadjuvant chemoradiotherapy. He received six weeks treatment for five days/week of continuous infusions with 5-FU and radiotherapy. The doses are not available.
 
TRUS following this treatment still showed a tumor at 5.5 cm from the dentate line T3N0
 
Surgery on 2.2006; no evidence of local or distant spread and a total proctocolectomy and ileoanal anastomosis and pouch was performed. Because the tumor was close to the resection margin a second ring of rectum distal to the initial resection line was removed. A protecting ileostomy was also performed. He had a stormy postoperative course with E. coli sepsis and mild renal failure (Cr 1.67 mg/dL). He received several antibiotics including gentamycin, contrast media during CT in this period. He was discharged 16 days after surgery.
 
Pathology report: showed residual well differentiated adenocarcinoma extending into the muscularis propria 0.5X0.5X1.5 cm reaching to 0.2 cm to the resection margin. The second ring of resected rectum showed no evidence of tumor. There were several adenomatous polyps (number not indicated) two showing high grade dysplasia and the remainder low grade dysplasia. There is nothing in the report concerning examination of lymph nodes.
 
A month following surgery the patient began chemotherapy with 5-FU 600 mg/sq m with leucovorin 500 mg/sq m once weekly for 4/6 weeks. He only completed one full cycle and in the second cycle the treatment was stopped because of severe diarrhea, repeated admissions for dehydration, Cr 1.8-2.0.
Following cessation of the chemotherapy it took several weeks for his condition to stabilize. The creatinine remains at 1.8.
 
In December 2006 a CT of the abdomen, ultrasound and endoscopic examination of the pouch as well as barium examination of the ileum distal to the ileostomy showed no evidence of local spread or recurrence.
 
On Jan 2007 the ileostomy was closed. The postoperative course was extremely stormy because of an anastomotic leak and fecal peritonitis which required two additional operations including construction of an ileostomy and closure of the abdomen after dehiscence of the abdominal wound. He was in intensive care for seven days.
 
Mr. Patient slowly recovered remarkably from this surgery and subsequently remained well.
 
In April 2006 an abdominal CT showed thickening around the pouch. There no further details of this finding.
Chest CT at that time suggested a mass in the lingula of the left lung but was reported finally as an area of fibrosis.

 

Expert's Opinion

""