title: Successful resection of metachronous para-aortic, Virchow lymph node and liver metastatic recurrence of rectal cancer.
abstract: A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, cSS, cN0, cH0, cP0, cM0 cStage II, Hartmann's operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, pSS, pN3, pH0, pP1, pM1 (para-aortic lymph node, dissemination) fStage IV. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography (CT) detected an 11 mm of liver metastasis in the postero-inferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of para-aortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in para-aortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine alone and continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome (Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Nobuyoshi
authors.initials: N
authors.lastname: Takeshita
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Toru
authors.initials: T
authors.lastname: Fukunaga
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Masayuki
authors.initials: M
authors.lastname: Kimura
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Yuji
authors.initials: Y
authors.lastname: Sugamoto
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Tasaki
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Isamu
authors.initials: I
authors.lastname: Hoshino
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Takumi
authors.initials: T
authors.lastname: Ota
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Tetsuro
authors.initials: T
authors.lastname: Maruyama
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Tomohide
authors.initials: T
authors.lastname: Tamachi
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Hosokawa
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Yo
authors.initials: Y
authors.lastname: Asai
authors.affiliation: Nobuyoshi Takeshita, Toru Fukunaga, Masayuki Kimura, Yuji Sugamoto, Kentaro Tasaki, Isamu Hoshino, Takumi Ota, Tetsuro Maruyama, Tomohide Tamachi, Takashi Hosokawa, Yo Asai, Department of Surgery, Numazu City Hospital, Shizuoka 410-0302, Japan.
authors.forename: Hisahiro
authors.initials: H
authors.lastname: Matsubara
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary* / Q000601:surgery*; D000368:Aged; D017024:Chemotherapy, Adjuvant; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000556:secondary* / Q000601:surgery*; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery*; D008207:Lymphatic Metastasis; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography; D012004:Rectal Neoplasms / Q000473:pathology* / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Liver metastasis; Long-term survival; Para-aortic lymph node metastasis; Peritoneal carcinomatosis; Rectal cancer; Surgical resection; Virchow lymph node metastasis