A Typical Metastasis of Colorectal Cancer: A Case Report and Literature Review
A Typical Metastasis of Colorectal Cancer: A Case Report and Literature Review
Abstract:- In the world: CCR ranks 4th (breast, prostate, II. CASE PRESENTATION
lung). In Europe, colorectal cancer is the second most
common cancer. In Morocco, at the National Institute of A 59-year-old woman, with a history of active smoking
Oncology in Rabat, CCR occupies 5th place (breast, at 25PA not stopped, treated at the Émile Durkheim Hospital
cervix, lymphoma, lung), 2nd digestive after stomach. in Épinal, France, was diagnosed in April 2021 with
Brain metastases occur in 1 to 4% of colorectal cancer Liberkühnian adenocarcinoma of the cecum with secondary
patients and its unique in 0.5% of patients. Due to its hepatic, peritoneal and lymph node involvement, classified
rarity, brain imaging is not recommended in the T4 N1 M1, MSS and mutated RAS. His baseline CEA level
systematic monitoring of these patients. According to the was 99.8 µg/dl. The initial diagnosis was an occlusive
literature review by Esmaeilzadeh et al, the prognosis for syndrome associated with a cecal tumour with invasion of
brain metastases from colorectal cancer is poor, with a liver segment V, lesion of segment IV and peritoneal
median survival of 5.2 months. In this paper, we report carcinomatosis. The patient received chemotherapy with
the case of a 59-year-old patient who was admitted for Folfox for a curative strategy, including 12 cycles from May
treatment of brain metastases from colorectal cancer. to October 2021, with a partial response. In February 2022,
she underwent right ileocolectomy, hepatic metastasectomy
Categories: of segments IV and VI, omentectomy, bilateral adnexectomy,
Digestive Oncology, Neurosurgery, Radiotherapy, followed by hyperthermic intraperitoneal chemotherapy with
Oncology mitomycin. In March 2022, during surveillance, progression
of a right lower lobar pulmonary nodule was detected and
Keywords:- Colorectal Cancer - Brain Metastasis, treated by stereotactic radiotherapy at the Lorraine Cancer
Neurosurgery, Radiotherapy, Chemotherapy. Institute in Nancy. The patient was well controlled until 15
November 2022, when she presented with disorientation and
I. INTRODUCTION behavioural disturbances. CT and MRI of the brain showed a
single lesion measuring 6 cm in diameter at the frontal level
In Europe, colorectal cancer (CRC) is the second most (Figures 1-6), with necrotic changes and perilesional oedema
common cancer (1). At diagnosis, 20% of people have (Figures 1,2). No other distant lesions were found. The patient
metastases (2), mainly in the liver and also in the lungs, rarely underwent a large but partial surgical excision of the brain
in the brain. MCs are typically derived from bronchial lesion on 5 December 2022 (vascular wound of the right
carcinoma cells, breast, periodontal or melanoma cells (3). In anterior cerebral artery). Pathological analysis revealed an
CRC, a solitary brain stem metastasis is even more adenocarcinoma compatible with a primary colorectal origin
phenomenal. In fact, previous research studies have reported (diffuse expression of CDX2 and SATB2) (Figure 7-9). She
the occurrence of brain metastases in CRC to vary from 1% was then treated with brain radiotherapy, which was
to 3% (4). Survival rates for people with lethal CRC (mCRC) completed in February 2023 and resulted in a marked
have been improving progressively with advances in improvement in her general condition, with no major
treatment. Typical survival for patients with mCRC is cognitive impairment or evidence of intracranial
currently around 21-24 months (5). As an outcome of long- hypertension. An abdominopelvic CT performed after
term survival with metastatic disease, the occurrence of brain completion of radiotherapy showed bilobar multifocal
metastases can be expected to improve patient survival". In hepatic progression, but no pulmonary progression. In the
the recommendations, radiological assessment of the brain to absence of a possible surgical indication, second-line
look for metastases is only recommended if there is a warning chemotherapy with FOLFIRI +/- AVASTIN was started from
sign (38). In the literature, brain metastases secondary to May to October 2023. On assessment, the ACE rate was high
colorectal cancer are rare; there are only case reports or case (3215 U/ml) and there was a 20-30% radiological liver
series (38). progression. Resumption of oral chemotherapy with
STIVARGA or LONSURF was considered, but given the
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Fig 6: Extra Axial Implantation Base with Images Interposition of Perilesional Cerebrospinal Fluid.
Invasion of the Fronto-Basal Cortex
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Brain metastases occur in 20-40 per cent of people with data. One third of these tumours are mutated for the KRAS
cancer, are symptomatic throughout life in 60-75 per cent of gene, the others are called "non-mutated". No abnormality of
people with cancer, or are discovered incidentally on CT/MRI the NRAS gene was observed. There was no significant
or at death (6). difference in their distribution as single or multiple based on
their molecular results. The majority of brain metastases of
Anatomical-clinical data of brain metastases treated in colorectal origin are single, whether mutated (70.6%) or not
Clermont-Ferrand from 2007 to 2017 (Table 1): In the series, (62.5%).
we observe 25 Lieberkühn adenocarcinomas with molecular
The professional discussion of brain metastases is people have focal neurological deficits, and seizures occur in
similar to the discussion of any type of intracranial mass about 15 to 20 per cent of people. Altered brain function or
lesion. Headache is a presenting sign and symptom in 40% to impaired cognition is regularly seen, especially in individuals
50% of patients with multiple metastases or with posterior with multiple metastases and/or increased intracranial
fossa tumours, and may be mild. Papilledema is the cause of pressure, in some cases resembling metabolic encephalopathy
headache in only 15-25% of individuals. Forty per cent of (39).
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Contrast-enhanced MRI is more sensitive than enhanced but the long-term effects of WBRT are of greater concern, as
CT (including double-dose delayed contrast) or unenhanced WBRT has been shown to significantly impair learning and
MRI in detecting brain metastases, especially posterior fossa memory function.
lesions or multiple punctate metastases(7, 8).Although T2-
weighted images are difficult to detect vasogenic oedema as As a result, it appears that WBRT can be withheld in
sites of increased signal intensity, not all metastatic brain has high-risk patients with stable systemic disease and a limited
enough oedema to be detected. In fact, some studies have number of brain metastases (one to three metastases) who are
reported that triple gadolinium doses are significantly better initially treated with either radiosurgery or surgery, if serial
than single doses(9,10). Metastases of 1 centimetre or more imaging is performed for follow-up. (28).
were easily seen with the reference doses and usually also
produce a T2 signal abnormality; triple-dose gadolinium was IV. CONCLUSION
slightly better at detecting 5-10 mm metastases and was three
times more difficult to detect lesions smaller than 5 mm (10). Brain metastases are rare and their treatment is a real
MRI is particularly indicated for people with a single challenge. Due to their location, they can quickly become
metastasis on CT who are candidates for stereotactic life-threatening. Dysphagia in a cancer patient cannot be
radiotherapy or surgical resection. (10). ignored and must be integrated with other symptoms and
signs to assess the need for brain imaging. With a precise and
Dexamethasone is the corticosteroid of choice, largely careful approach, neurosurgery followed by adjuvant SBRT
because of its minimal mineralocorticoid effect. Up to 75% radiotherapy can help control metastases, at least the
of patients with brain metastases show marked clinical symptoms associated with them, as demonstrated in this
improvement within 24 to 72 hours of starting clinical case, aggressive multidisciplinary treatment can offer
dexamethasone. (11). improvement in quality of life and potentially survival.
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