PMC7569264_01
(A-B) A contrast-enhanced CT scan showing a mass involving the splenic flexure extending for approximately 5.2 cm in length. (C-D) Anterior abdominal wall collection with a thick wall measuring 13 x 3.5 x 9 cm on its maximum transverse likely to be seroma. The liver is enhancing homogeneity and appears to be pulled to the anterior abdominal wall likely due to fibrosis, stable hemangioma at segment VII measuring 2.6 cm in diameter. The small bowel is the anterior abdominal wall without obstruction.
gr1.jpg
PMC7569264_01_gr1.jpg
fig0005
The erect abdominal x-ray showed multiple air-fluid levels and the abdominal computed tomography (CT) scan was significant for focal circumferential wall thinning of the splenic flexure causing stricture with proximal colonic and small bowel distension (Fig. 1A, B). Seven months later CEA increased from <0.5 to 10.3 and evaluation by CT-scan showed soft tissue nodules at the surgical site indicating recurrence, a mass invading the lower 4 costal cartilage, and a query liver lesion at segments 3 and 4 (Fig. 1C, D).
(A) Histological examination of the colonic mass shows infiltration by variably sized malignant glands with pools of intra and extra glandular mucin. (B-C) Infiltration of the breast and the axillary lymph node by adenocarcinoma showing similar histological features of the primary colonic adenocarcinoma. (D-E) Well-controlled immunohistochemical stains show that the neoplastic cells in the metastasis are positive for CK20 and CDX2 supporting a primary colonic origin.
gr2.jpg
PMC7569264_01_gr2.jpg
fig0010
Histological examination of the sections taken from the mass revealed low-grade mucinous adenocarcinoma with no lymph node metastasis and negative surgical resection margins pT3N0Mx (Fig. 2A). The specimen was confirmed as metastatic adenocarcinoma with positive CK20, CDX2 while negative for CK7, GCDFP15, GATA-4, estrogen (ER) and progesterone (PR) (Fig. 2B-E).
(A) Fluorodeoxyglucose (18F) PET/CT scan of the abdomen showing intense heterogeneous uptake in upper anterior abdominal wall measuring roughly 8.5 x 2.5 cm. (B) Fluorodeoxyglucose (18F) PET/CT scan of the abdomen showing interval progression in size of FDG activity of a soft tissue nodule at in the right upper anterior abdominal wall, with SUVmax of 7.7. New FDG avid peritoneal nodulehepatic focal lesion at the tip of the right hepatic lobe adjacent to the capsule of segment IV with SUVmax of 4.8. Small seroma fluid collection in the midline upper abdominal wall measuring 4.5 x 0.9 cm surrounded by FDG avid wall and fat stranding suggestive of an inflammatory process.
gr3.jpg
PMC7569264_01_gr3.jpg
fig0015
Positron emission tomography with 18-F fluorodeoxyglucose integrated with CT (18F-FDG-PET/CT) showed a metastatic solitary upper abdominal mass (Fig. 3A). After 6 months of follow-up, the patient's CEA level elevated from 6.92 to 19.46, and the 18F-FDG-PET/CT showed a new FDG avid peritoneal nodule and hepatic focal lesion (Fig. 3B).
Ultrasound imaging of the right breast showing 9 o'clock hypoechoic anti-parallel mass measuring 1.6 x 0.8 x 2.1 cm, suggestive of highly aggressive malignancy with BIRADS V.
gr4.jpg
PMC7569264_01_gr4.jpg
fig0020
The patient had an ultrasound of the right breast and axilla which showed a mass and followed by an ultrasound-guided biopsy (Fig. 4).