Isolated metastasis of colon cancer to the scapula: is surgical resection warranted?

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.

The benefit of surgical management of colorectal carcinoma bone metastases

“…Skeletal metastases are often associated with synchronous disease of the liver and lungs, making isolated skeletal metastases even more uncommon, at 1-2 percent [14] . The mechanism is thought to be primarily via either the venous plexus/IVC, lymphatic chains, or through the portal vein [12] .…”

“…Consistent with this observation, in our study 26 of the 39 patients had a metastasis in the femur. Other frequent sites include the humerus and skull [5,14] .…”

“…Among these, rectal carcinoma metastasizes more often to bone, with a reported incidence of 3.8 to 10.5 percent [5] . Skeletal metastases usually occur after widespread metastatic disease, and are usually osteolytic or mixed osteolytic/osteoblastic [5,14,22] . The most common site in the axial skeleton is the femur [1,5] .…”

“…Skeletal metastases most often occur in the spine [5,16] . Proximal long bone involvement (femur and humorous) is seldom observed, and distal long bone involvement (tibia, fibula, radius, ulna, hands, feet) is exceedingly rare [1,7,14,16,[18][19][20][21] .…”

“…In contrast, there have been studies to determine prognostic variables with metastasis to other organs [4-6, 9, 10] . The incidence of BM from colorectal cancer ranges from 9%-11% in autopsy cases, to 5%-11% in clinical series [4,5,8,[11][12][13][14] . Several studies correlate the site and number of metastasis to other organs with patient survival [5,9,13,[15][16][17] .…”