|Year : 2014 | Volume
| Issue : 2 | Page : 413-415
Ranen Kanti Aich1, Ghosh Suman2, Gupta Phalguni1, Bhattacharya Jibak1, Das Diptimoy3
1 Nil Ratan Sarkar Medical College and Hospital, Kolkata, India
2 Department of Pathology, Nil Ratan Sarkar Medical College and Hospital, Kolkata, India
3 Department of Radiotherapy, Midnapur Medical College, West Midnapur, West Bengal, India
|Date of Web Publication||14-Jul-2014|
Ranen Kanti Aich
Department of Radiotherapy, Nil Ratan Sarkar Medical College and Hospital, Kolkata - 700 014, West Bengal
Source of Support: None, Conflict of Interest: None
Rectal cancers may rarely metastasize in bone and when it occurs, is usually preceded by lung and/or liver metastasis. However, whether it may ever bypasses other organs, particularly lung and liver and metastasizes directly to bone or not, is debatable. Some authors have described the presence of isolated bone metastasis from colo-rectal cancers, whereas others have questioned its' existence in the absence of lung or liver metastasis. A case of isolated bone metastasis from rectal cancer in the absence of lung or liver metastasis is reported here.
Keywords: Bone metastasis, distal metastasis, rectal cancer
|How to cite this article:|
Aich RK, Suman G, Phalguni G, Jibak B, Diptimoy D. Bone metastasis. J Can Res Ther 2014;10:413-5
| > Introduction|| |
Osseous metastasis from rectal cancer is an uncommon entity and when occurs, is usually following liver or lung metastasis. A young male, who was treated for rectal cancer 2 years back, developed swelling and pain of left knee joint, which on fine needle aspiration cytology turned out to be a metastasis from the previous rectal cancer. Computerized tomography (CT) of the lungs and liver showed no evidence of metastasis proving, it to be a case of isolated bone metastasis from rectal cancer. The patient was treated with palliative radiotherapy to the knee joint followed by chemotherapy.
| > Case Report|| |
In March 2010, a 32-year-old male presented himself with history of bleeding per rectum usually mixed with stool for last 2 months. Per rectal examination and colonoscopy revealed an ulcerated growth abutting the anal sphincter and occupying almost 75% of the circumference; Biopsy proved it to be moderately differentiated adenocarcinoma of rectum. Computerized tomography (CT scan) of whole abdomen and Trans-rectal ultra-sonography revealed the tumor invading through the muscularis propria and two Para-rectal lymph nodes ≈ 1 cm in size. Routine blood examination, liver, and kidney function tests and chest X-ray were within normal limits and serum CEA was 6 ng/ml. Abdomino-pereneal resection was done and pathologically it was a P T3 N 1 disease (Dukes C 1 ). Four weeks after surgery, pelvic radiotherapy was started (5040 cGy/28F/5.5 weeks) along with concurrent chemotherapy (Inj. 5FU-500 mg/M 2 bolus, Day-1 to Day-5, repeated from Day 29 × 2 cycles) followed by four more cycles of same chemotherapy. Patient tolerated the treatment well, became symptom free, and was put on periodical check-up with the clinical examination, chest X-ray, CT scan/USG abdomen and serum CEA estimation.
In May 2012, the patient developed a gradually increasing swelling and pain of left knee joint, X-ray of which showed a reduced lateral joint space, normal sub-articular bones, and eroded lower anterior cortex of femur. Magnetic resonance imaging revealed irregular shaped T 2 heterogeneous hyper intensity and T 1 hypo-intensity in lower shaft and adjacent epiphysis of femur anteriorly with destruction of cortical margin and extension into adjacent soft-tissues [Figure 1]. Menisci, articular cartilages, cruciate, and collateral ligaments were normal. CT guided needle biopsy from the bone lesion turned out to be 'metastatic deposit of adenocarcinoma' [Figure 2]. A biopsy from the metastatic site and positive immunohistochemical examination for surface antigen would be more suggestive, though it may be negative as well. Immunohistochemical examination of the three epitopes B 72.3, CC-49 and CC-83 of the tumor associated glycoprotein 72 would be more confirmatory but could not be carried out due to logistical deficiencies. CT scans of chest and abdomen [Figure 3], colonoscopy, routine blood examination, liver and kidney function tests and serum CEA level showed no abnormality. 99 mTc-MDP bone scan showed increased uptake at the knee joint, but not at any other site. PET scan was suggested, but the patient could not afford it. Therefore, it was diagnosed to be an isolated bone metastasis from the previous rectal carcinoma. Radiotherapy was delivered to the knee joint with adequate margins, pain was almost relieved, but swelling not so much and the patient subsequently received chemotherapy with FOLFOX-4 regimen. The patient is now on regular follow-up though the swelling is still persisting.
|Figure 1: Magnetic resonance imaging of left knee joint showing hyper intense lesion at the lower end of femur|
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|Figure 2: Needle biopsy from bone lesion showing "metastatic deposit of adenocarcinoma" (H and E, ×400)|
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|Figure 3: Topogram of chest and abdomen showing no lung or liver metastasis|
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| > Discussion|| |
Colorectal cancer is the third leading cause of cancer-related deaths in the world and death is usually attributed to disease progression with recurrence and metastases. Skeletal metastasis from colorectal cancer is an uncommon event and when occurs, is usually a late manifestation of the disease and is usually preceded by liver or lungs metastasis. The most common sites of osseous metastases are the vertebral, pelvis and the sacral regions, and paravertebral venous plexus of batson is considered to be the possible route of spread. 
To find out the incidence of skeletal metastasis, Katoh et al.,  analyzed the clinical and autopsy records of 118 patients with the primary colorectal cancer treated either surgically or conservatively and eventually autopsied and found bone metastasis in 23.7% of cases, but the metastases were associated with liver or lung metastasis. In their report, cancers of rectum and caecum were associated with bone more frequently than cancers of other parts of colon. Similarly, Kanthan et al.,  reviewed 5352 cases of colorectal carcinoma and found osseous metastasis in 355 patients. Among them, 16.9% cases had skeletal metastasis only, whereas in 83.1% cases, skeletal metastasis was combined with liver, lung or brain metastasis. In their review, the incidence of solitary bone metastasis from colorectal carcinoma turned out to be 1.1% only. Nozue et al.,  found the incidence of bone metastasis to be far lower (1.3%), only 12 in 928 resected colorectal cancer patients, but nine of the 12 cases had other metastatic sites, that is only three patients had bone metastasis alone (0.32%). The majority of primary tumors were located at the rectosigmoid portion of the colon and bony metastases were concentrated in the lumber and pelvic bones.
The presence of skeletal metastasis in the absence of lung or liver metastasis was questioned by Roth et al.,  They used F-18-flurodeoxyglucose-PET scan to determine whether colorectal cancers can bypass lungs and liver to metastasize in bone and whether lung metastasis is better than liver metastasis in predicting bone metastasis. They concluded that metastasis only to bone without other organ involvement is extremely rare, perhaps more rare than previously thought. Their findings also suggested that resistant metastasis to the lungs predicts potential disease progression to bone in the colorectal cancer population better than liver metastasis does.
Time interval of bony metastasis following treatment of colo-rectal cancers and their survival following diagnosis are also variable. Talbot et al.,  reported symptomatic bone metastases a median of 21 months after initial surgical excision of the primary tumor. Chalkidou et al., reported a solitary tibial metastasis from rectal cancer 12 months after surgery.  In our case the metastasis was diagnosed 26 months after resection of the tumor. Survival after bone metastasis is very poor, with a median time of 5 months when associated with visceral metastasis also. Kanthan et al.,  found that 38% with bone only versus 16% with bone and visceral metastasis were alive at 5 years. Seven months have elapsed since the diagnosis of bone metastasis in the present patient and he is still carrying out his routine activities.
Sundermeyer et al.,  reviewed 1020 cases of colorectal cancer and found that the incidence of bony metastasis increases with increased number of systemic agents used. Patients receiving ironotecan or oxaliplatin were more likely to develop bone metastasis and rectal cancer patients were more prone to develop bone metastasis than colon cancers.
| > Conclusion|| |
Bone metastasis from colorectal cancer is not so uncommon as previously thought. They are becoming more apparent as more loco-regional controls are achieved with aggressive therapy using multi-agent chemotherapy and their early detection improves quality of life as well as survival.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3]