PMC7276394_01
I-a, b, c) Three metastatic lesions noted in the liver (S4: size 44 mm, S8: size 45 mm, and S5: size 35 mm).. I-d) Suspected tumor progression along Glisson 5 (red arrow).. I-e) A retropancreatic LN of size 12 mm is seen (red arrow).. II-a, b, c) All liver metastatic lesions reduced in size (S4: size 30 mm, S8: size 40 mm, S5: size 28 mm).. II-d) Tumor progression along Glisson 5 is more evident (red arrow).. II-e) Retropancreatic LN have reduced in size (10 mm; red arrow).. III-a, b, c) DWI-MRI revealing high intensity areas concomitant with the liver metastases.. III-d) DWI-MRI showing high intensity signal along Glisson 5.. III-e) DWI of MRI showing high intensity signals in the retropancreatic LN.. IV-a, b, c, d, e) DWI-MRI revealing high intensity signals consistent with suspected metastatic lesions.. V-a, b, c, d, e) PET revealing high intensity signals, all consistent with suspected metastatic lesions including retro-pancreatic LN.. VI-a, b, c) Although S5 metastasis still shows a weak intensity signal, there is no detectable signal intensity in the S4 and S8 metastases.. VI-d, e) PET does not show any signal intensity in Glisson 5 and the retropancreatic LN.
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On comparison of the pre- and post-chemotherapeutic computed tomography (CT) images, the size of the liver metastasis in segment 8 of the liver (S8) had reduced from 45 mm to 40 mm, metastasis in S4 reduced from 44 mm to 30 mm, and metastasis in S5 reduced from 35 mm to 28 mm following chemotherapy (Fig. 1; I-a~c and II-a~c). Additionally, the retropancreatic lymph node reduced in size from 12 mm to 10 mm (Fig. 1; I-e and II-e). Regarding the positron emission tomography (PET) evaluation, the signal intensity was strong in all the liver metastases and retropancreatic LN prior to chemotherapy (Fig. 1; V-a~e). However, there was an absence of signal intensity in the liver metastatic lesions with the exception of the S5 metastasis after chemotherapy (Fig. 1; VI-a~e). On the diffusion-weighted imaging (DWI) of magnetic resonance imaging (MRI), apart from the liver metastases and retropancreatic LN, Glisson 5 also displayed signal hyperintensity both, before and after chemotherapy (Fig. 1; III-a~e and IV-a~e).
(a) Intraoperative ultrasound clearly showing suspected tumor progression along Glisson 5. However, it has not reached the root of Glisson 5.. (b) An enlarged retroperitoneal LN is observed.. (c) Surgical field after anatomical liver S4 and S5 sub-segmentectomy.. (d) On histopathological examination, viable adenocarcinoma cells are detected in all the liver metastatic lesions.. (e) Viable adenocarcinoma cells are detected in the resected retropancreatic LN.. (f) Immunohistological staining using D2-40 antibody showing cancer cells in the lymphatic duct of Glisson 5.
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Based on the above evaluation, we decided to perform anatomical sub-segmentectomy of S4 and S5, partial resection of S8, and sampling of the enlarged retropancreatic LN (Fig. 2c). As a notable intraoperative finding, we could see an enlarged and echogenic Glisson 5, which probably came from the adjoining S5 metastasis, but did not reach the root of Glisson 5 (Fig. 2a). In addition, we could see enlarged retropancreatic LN as expected, and performed sampling from it (Fig. 2b). On histopathological examination, both, viable and necrotic adenocarcinoma cancer cells from rectal cancer were detected in the metastatic liver lesions, Glisson 5, and the retro-pancreatic LN (Fig. 2e). D2-40 antibody demonstrated cancer cells within the lymphatic duct of Glisson 5 (Fig. 2f). During the post-operative period, the patient received adjuvant chemotherapy for six months.
PMC7276394_02
I-a, b, c) Three liver metastatic lesions (S6: size 35 mm, S7: size 23 mm, S3: size 13 mm). In addition, suspected tumor progression is seen along Glisson 6 (red arrow).. I-d) Small LN detected in the hepatoduodenal ligament.. II-a, b, c) In addition to the previous three liver metastatic lesions, one more metastasis is detected in S3. Furthermore, suspected tumor progression along Glisson 6 has become more evident (red arrow).. II-d) LN in the hepatoduodenal ligament have increased in size when compared to the CT before chemotherapy.. III-a, b, c, d) DWI-MRI displayed high intensity signals consistent with liver metastatic lesions. However, no signal intensity has been detected in the hepatoduodenal LN.. IV-a, b, c) DWI-MRI shows high intensity in not only all the liver metastatic lesions including the new S3 metastasis, but also in Glisson 6 and the hepatoduodenal LN (yellow arrow).. V-a, b, c, d) PET revealing high intensity signal consistent with all the liver metastatic lesions and Glisson 6, but not in the hepatoduodenal LN.. VI-a, b, c, d) PET shows high intensity signals not only in all the liver metastatic lesions, but also Glisson 6 and the hepatoduodenal LN.
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Subsequent to colorectomy, radiographic images for re-evaluation revealed additional liver metastatic lesions in S3 in addition to the pre-existing ones in S6 and S7 (total 3 liver metastases; S6: size 35 mm, S7: size 23 mm, S3: size 13 mm), along with suspected tumor progression along Glisson 6, which probably came from the adjoining S6 metastasis (Fig. 3; I-a~c). However, post-chemotherapeutic examination by CT and MRI revealed an additional S3 liver metastasis (total 4 liver metastases; S6: size 35 mm, S7: size 17 mm, S3: size 9 mm and 7 mm) (Fig. 3; II-a~c and III-a~c). Positron emission tomography-computed tomography (PET-CT) detected standardized uptake value (SUV) accumulation in a hepatoduodenal LN, considered as tumor metastasis for the first time (Fig. 3; VI-d). The tumor progression along Glisson 6 also became more evident on comparing images from before and after chemotherapy (Fig. 3; I~VI-a).
(a) Intraoperative ultrasound clearly showing suspected tumor progression along Glisson 6. However, it has not reached the root of Glisson 6.. (b) An enlarged LN is observed at the hepatoduodenal ligament (yellow arrow).. (c) Surgical field after dissection of the hepatoduodenal area.. (d) On histopathological examination, viable adenocarcinoma cells are seen in all the liver metastatic lesions.. (e) Viable adenocarcinoma cells detected in the resected hepatoduodenal LN.. (f) Immunohistological staining using D2-40 antibody shows cancer cells in the lymphatic duct of Glisson 6.
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Histopathological examination revealed adenocarcinoma cancer cells from colon cancer, that were detected not only in all the liver metastatic lesions detected by preoperative imaging, but also in the hepatoduodenal LN (Fig. 4d). In addition, metastatic cancer cells from liver segment S6 invaded and progressed along Glisson 6, consistent with the preoperative images (Fig. 4e). D2-40 antibody demonstrated cancer cells within the lymphatic duct of Glisson 6 (Fig. 4f). During the post-operative period, the patient could not receive adjuvant chemotherapy owing to severe fatigue.