Presentation
Abdominal pain and loss of weight. No relevant prior history. Otherwise well.
Patient Data
In the mid sigmoid colon there is an irregular mass, with soft tissue extension outside of the colonic serosa into sigmoid mesocolon. Small regional nodules along the mesocolon are likely involved lymph nodes.
There is a large low density mass arising from the pelvis, with multiple loculations and solid components. This mass abuts the uterus and possibly arises from an ovary, although its exact origin is unclear. The mass also abuts the proximal and mid sigmoid colon, without upstream colonic distension.
The liver contains innumerable hypodense lesions highly suggestive of metastases. Previous cholecystectomy with biliary dilatation, which may be acceptable in the postcholecystectomy state.
Low density lesions are also present in the spleen. Additionally there is extensive omental nodularity and irregular soft tissue thickening along the lower aspects of the paracolic gutters.
Conclusion:
Findings are highly suggestive of primary sigmoid carcinoma with extensive metastases to the peritoneum, liver and possibly spleen. The large pelvic cystic mass is likely an ovarian metastasis.
Case Discussion
This is a case of metastatic sigmoid cancer, which was confirmed on surgery. When faced with such extensive metastases the primary can often be overlooked, thus a careful search must be made.
This is also instructive in the sense that the pelvic tumor can be extremely confusing, and only after finding the sigmoid cancer does the case come together. An alternative differential that may have been given is of primary ovarian carcinoma, which is also known to often spread to the peritoneum. Alternative sites of primary carcinoma to look for would include the stomach, appendix and pancreas.
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