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LOWER RECTAL CANCER METASTASIS IN THE RIGHT INGUINAL LYMPH NODE: CASE REPORT
Apresentação do caso
Male, 57 years old, sought care at a tenesmus clinic, blood in the stool and weight loss of 10 kg in 8 months. A colonoscopy was performed, which showed a lesion in the lower rectum and anatomopathological examination demonstrating an invasive moderately differentiated adenocarcinoma. The patient followed with local and systemic staging, tomography (CT) and resonance (MRI) indicating a cT2N1M0 tumor. The total neoadjuvant chemotherapy protocol was started, with induction with FOLFOX in 8 cycles. Followed up with radiotherapy (28 sessions - 50.4Gy) with concomitant capecitabine. At restaging, MRI and flexible rectosigmoidoscopy showed poor tumor response to neoadjuvant therapy. A multidisciplinary meeting defined surgical treatment for total mesorectal excision. On admission to the hospital for surgery, the patient had asymmetric edema in the entire right lower limb, swelling of the right calf, no pain on dorsiflexion and bilaterally palpable arterial pulses. Followed up with venous Doppler ultrasound of the right lower limb and CT that demonstrated compression of the right external iliac vein (VIE) due to adenomegaly. Incisional biopsy of lymph node enlargement was chosen for diagnostic clarification. Pathological examination revealed metastatic adenocarcinoma in the right inguinal lymph node, immunohistochemistry favoring primary neoplasm in the large intestine (positive CDX2 and CK20).
The clinical case demonstrates evolution from local disease to metastatic disease in a rare site during treatment with total neoadjuvant therapy (TNT) and induction protocol, meaning a challenging prognosis for the multidisciplinary team. In addition to altering the staging, the impairment of the local circulation, compressing large vessels, such as the VIE, causing edema in the lower limb and simulating a picture of deep vein thrombosis. The literature shows that cases like the one reported, although with a worse prognosis compared to the absence of distant lymph node metastasis, can benefit from treatment with curative intent. The choice of TNT before surgery aims to provide uninterrupted systemic therapy to eradicate micrometastases.
The present case is noteworthy for the rarity of the diagnostic association with the presentation of lymphedema, a relationship that has been rarely described in current medical literature.
colorectal cancer; lymphedema; malignant neoplasm
Tumores coloretais e canal anal*
RODRIGO FIRMINO SCHIRMBECK MORAES, CARLOS ANDRE DOS SANTOS CARNEIRO, GERMANO DANIELLI, ANELIZE ZAGONEL, FRANCISCO LEMANSKI, GABRIELA HAMMACHER, NICOLLE MESQUITA, EMANUELA LANDO, JOSE FRANCISCO PARIZOTTO, MIGUEL DUDA SCHMITZ