PMC8649836_01
Imaging examinations performed before surgery. Enhanced CT scans on March 21, 2020 of abdomen revealed that occupying lesions in the middle and upper rectum, the intestinal lumen was narrowed, and the serosal layer was hairy. After enhancement, the lesion was uneven and enhanced, and the length of the lesion was about 5.7 cm, considering that was rectal cancer (T4aN1M0).
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Considering the possibility of rectal cancer, CT findings were consistent with T4aN1M0 ( Figure 1 ).
Histopathological examination of tumor. (A) Hematoxylin and eosin (H&E) staining of colonic primary tumor shows glandular differentiation and invasion into the entire intestinal wall (x20). (B) Poorly differentiated adenocarcinoma on the surface of mucosa with multiple intravascular thrombus in submucosa, (x40). (C) Metastatic tumors can be seen in lymph node, (x40). Immunohistochemical staining of tumor cells. Ki-67 partial expression in tumor (+70%) (D, x100), CKpan expression in tumor (E, x100.), Immunostaining for MLH1 (+70%) (F, x100), MSH2 (+70%) (G, x100), MSH6 (+80%) (H, x100)and PMS2 (+50%) (I, x100) confirmed the tumor with proficient MMR.
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Immunohistochemistry results were as follows: pMMR, Ki-67 (+70%); CKpan (+), P53 (-), CgA (-), and Syn (-) ( Figure 2 ).
Imaging examinations performed after chemotherapy. (A) After five cycles of XELOX, CT scans on August 12, 2020 revealed enlargement of the abdominal para-aortic and bilateral para-iliac lymph nodes, about 0.5-1.5 cm, with slightly enhanced. (B) After six cycles of FOLFIRI plus cetuximab treatment, CT scans on November 28, 2020 revealed significant enlargement of lymph nodes in the hilar area, adjacent to the abdominal aorta, and bilateral iliac vessels, with a maximum of about 2.3 cm and slightly enhancement. (C) MRI scans on November 29, 2020 show patchy shadows are seen on the right femoral head and greater trochanter, enhanced scans are seen to be enhanced, consider metastasis. (D) CT scans on December 22, 2020 showed hydronephrodilation of the right renal pelvis and space-occupying lesion about 16.2 mm x 9.3 mm in the initial segment of the right ureter.
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The CT and MRI evaluations were progressive disease (PD) after chemotherapy, detecting significantly enlarged lymph nodes around the abdominal aorta (0.6-1.5cm) on August 12, 2020 ( Figure 3A ). On November 28, 2020, CT and MRI scans indicated PD, detecting a lymph node around the abdominal aorta enlarged to 2.3 cm ( Figure 3B ), tumor metastases to the right femoral head and greater trochanter ( Figure 3C ), and left cervical lymph nodes enlarged to 11 mm x 8 mm. Likewise, abdominal CT scans indicated PD again, observing a space-occupying lesion (1.6 cm x 0.9 cm) in the initial segment of the right ureter on December 22, 2020 ( Figure 3D ).