Aug 26, 2010 - Indian Society of Gastroenterology 2010. Abstract. Objective To assess the incidence of synchronous colorec- tal liver metastasis in patients ...
Indian J Gastroenterol (2010) 29:149–151 DOI 10.1007/s12664-010-0041-0
ORIGINAL ARTICLE
Synchronous liver metastasis in colorectal cancer in Sri Lanka Rohan Chaminda Siriwardana & S. Ruwan E. Wijesuriya & Sumudu K. Kumarage & Kemal I. Deen
Received: 6 November 2009 / Accepted: 9 August 2010 / Published online: 26 August 2010 # Indian Society of Gastroenterology 2010
Abstract Objective To assess the incidence of synchronous colorectal liver metastasis in patients referred to a tertiary referral center in Sri Lanka and to evaluate the differences in the clinicopathological features of patients with and without synchronous metastasis. Methods Records of 438 patients were retrospectively analyzed. Patients were classified into metastatic group (n=34, 8%) and non metastastatic group (n=404, 92%). In the two groups macroscopic features compared were: tumor size (2 cm, 2–5 cm, and >5 cm), site of primary tumor and side of liver involved. Carcinoembryonic antigen (CEA) levels were recorded. At microscopy, tumor differentiation, invasion and nodal status were evaluated. Results The rectum was the primary site of the tumor in a majority (60%) of patients. There was no difference in the distribution of the primary site and size of the tumor, pathological stage, lymphatic infiltration and the degree of tumor differentiation in two groups (p>0.05). Patients with metastasis had higher levels of CEA, higher frequency of vascular infiltration and N3 nodes involved (p5 cm), site of primary tumor and side of liver involved. Carcinoembryonic antigen (CEA) levels were recorded. At microscopy, tumor type, invasion and nodal status were evaluated [4]. Statistical analysis was done by comparison of proportions using Chi square list. A p value 0.05) in patients with liver metastasis (3.7 cm [range 1.5–11]) and without metastasis (3.5 cm [1.2–9.5]). There were no T1 tumors in patients with liver metastasis. The distribution of T2, T3 and T4 tumors was equal in both groups. In patients with liver metastasis, metastatic lymph nodes were found in 70% of patients compared to 43% without metastasis. A significant higher number of patients with liver metastasis had vascular
Table 1 Comparison of colorectal cancer patient characteristics between those with and those without synchronous liver metastasis
Discussion In our cohort of patients the incidence of synchronous liver metastasis was 8%. The patients with metastasis had higher frequency of vascular invasion, lymphatic infiltration, N3 nodal involvement and higher CEA levels. Synchronous liver metastases are reported in 20–30% of patients with colorectal cancer from western countries. The presence of synchronous liver metastasis is considered a poor prognostic factor. Tasi et al. compared synchronous metastasis with metachronous lesions and found that synchronous lesions are aggressive and carry a poor prognosis [5, 6]. Early manifestation of liver metastasis probably reflects the aggressive nature of the tumor. The definition of synchronous liver metastasis is variable. Some authors consider lesions diagnosed up to 3 months from the detection of the primary lesion as a synchronous deposit [5, 6]. Tumor seeding into circulation from the
With metastasis n=34 Mean (SD) age (years) Gender Site of tumor
CEA level (ng/mL) (median [IQR]) Tumor stage
Lymph nodal stage
Vascular invasion Lymphatic invasion Differentiation
Data are as n (%)
invasion (p=0.001). However, lymphatic infiltration was equal in both groups (p=0.94). In those with liver metastasis, the median value of CEA was 15.3 ng/mL (IQR 4.8–162) with 21 (61%) having a CEA level above 10 ng/mL. In those without metastasis, the median CEA level was 5 ng/dL (IQR 2.5–12). Eightyfour (21%) patients had CEA level above 10 ng/dL.
Male Female Rectum Sigmoid colon Left colon Right colon T1 T2 T3 T4 N0 N1 N3
Well Moderate Poor
57 (10.57) 21 (61%) 13 (39%) 22 (64.6%) 8 (23.4%) 1 (3%) 3 (9%) 15.3 (4.8–162) 0 6 (17%) 20 (60%) 8 (23%) 10 (30%) 10 (30%) 14 (40%) 12 (36%) 4 (12%) 4 (12%) 27 (79%) 3 (9%)
Without metastasis n=404
p
58 (14.7) 206 (51%) 198 (49%)
0.69 0.34
262 57 28 57 5 32 69 214 89 231 93 80 48 56 71 300 32
1 0.24 0.59 0.56 0.004 – 1 0.50 0.95 0.004 0.47 0.012 0.001 0.94 0.6 0.6 1.0
(65%) (14%) (7%) (14%) (2.5–12) (8%) (17%) (53%) (22%) (57%) (23%) (20%) (12%) (14%) (17.5%) (74.5%) (8%)
Indian J Gastroenterol (2010) 29:149–151
primary site ceases once it is resected; however, remaining surviving cells in the liver are likely to emerge as secondary deposits, depending on the host and tumor characteristics. After surgery, it is essential to identify this sub-group of patients who are at a higher risk of developing metachronous lesions. Synchronous and metachronous deposits are likely to be a result of the same pathological process. Risk factors associated with synchronous metastasis are likely to carry a higher risk of subsequent metachronous lesions. Thus, relationship of CEA level greater than 10 ng/mL, advanced nodal stage and presence of vascular invasion with development of metachronous metastasis needs to be further investigated. Despite comparable stage of cancer at presentation [7], the incidence of synchronous lesions in our patients is low compared to western figures of 20–30%. Koo et al., analyzing 1,469 patients from a multi ethnic population found a lower incidence of synchronous metastasis of 12% in Asian migrants compared to 21% in Australians [7]. Norwood et al. found that a significant number of South Asians were younger at presentation, had more rectal tumors, were more likely to require initial chemotherapy and were less likely to have resectional surgery than Caucasians [8]. These data suggest that tumor biology is different among Asians. Further data such as incidence of metachronous liver metastases in our population needs to be generated in order
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to determine whether western guidelines for management are applicable in South Asia as well.
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