CASE PRESENTATION:
A 71-year-old ex-serviceman was referred to the Department of Surgery from the Department of Oncology with a history of splenic metastasis secondary to colorectal carcinoma. During the initial visit to our hospital two years ago, he presented with complaints of no passage of stool and flatus, abdominal pain, and tenderness, consistent with peritonitis, which had persisted for three days. Immediate resuscitation and investigations were performed, including a computed tomography (CT) scan that revealed an obstructing growth in the sigmoid colon.
Given the patient’s clinical presentation of abdominal pain and tenderness, suggestive of peritonitis, he underwent emergency laparotomy, during which a sigmoid mass was excised, and a loop ileostomy was performed. The postoperative recovery was uneventful. Histopathological examination of the specimen revealed a well-differentiated adenocarcinoma of the sigmoid, perforating the serosa (pT4), with perineural invasion. The margins were negative, and four out of the 16 lymph nodes were involved, leading to the classification of the tumor as stage III (pT4bN1b, AJCC). The patient subsequently underwent ileostomy reversal two months after the surgery. The patient was discharged and referred to the Department of Oncomedicine for adjuvant chemotherapy.
Two years later, a follow-up CT scan found metastasis in the spleen. PET CT of the whole body with contrast revealed splenic metastasis with multiple FDG avid hypodense lesions, the largest measuring 6.6X4.3 cm with an SUV max of 6.1 cm Fig1 . However, no recurrence was detected along the anastomotic site in the sigmoid, and no bony or bone marrow lesions were found.Any other remote organ metastases were not found by both CT and PET scanning. Clinical examination did not reveal any palpable spleen, and the patient subsequently underwent laparoscopic splenectomy Fig 2 . The surgical findings in this case indicate that the metastatic tumor was localized to the spleen without any capsule invasion macroscopically. There were also no metastases detected in other intra-abdominal organs or lymph nodes at splenic hilus or para-aortic site. Therefore, lymphadenectomy was not performed during the operation.The postoperative period was uneventful, and post-splenectomy vaccination and antibiotics were initiated. Histopathological report revealed metastatic adenocarcinoma with no capsule invasion Fig 3 . Adjuvant chemotherapy was started, and at the one-month follow-up, the patient was doing well.