A 71-year-old Chinese female with a history of colon cancer, thyroid cancer and hypertension referred to our hospital for a two-month history of recurrent abdominal discomfort in December 2018. She had received treatment for colon cancer (pT4N1M0), right hemicolectomy with D3 lymph node dissection on the right midline of the superior mesenteric artery in June 2017. Pathology revealed ulcerative adenocarcinoma of medium-low differentiation, infiltrating into extra-intestinal adipose tissue, with vessels and nerves invaded and 1 of 12 positive lymph nodes. 4 cycles of Xelox chemotherapy (oxaliplatin and capecitabine) and 4 cycles of oral Capecitabine chemotherapy were administered post-operation during a period of 6 months. In December 2017, she received total thyroidectomy with left-sided cervical lymphadenectomy and central neck dissection. Histologic evaluation of the thyroid tumor (pT1N1M0) showed a classic variant of papillary thyroid cancer of the left thyroid lobe measuring 2*2 cm and a right mini-papillary thyroid cancer measuring 0.3 cm (Fig. 1). There was no tall cell, columnar, or diffuse sclerosing variant to suggest aggressive tumor biology. There was vascular and capsular invasion, and 3 of 6 lymph nodes contained metastatic papillary thyroid cancer (Fig. 1). The patient refused further 131I radiotherapy and was given thyroid-stimulating hormone (TSH) suppression therapy.
Thorough examination was performed after admission. Physical examination exhibited an enlarged uterus with obscure boundary and signs of subxiphoid tenderness. A computed tomography (CT) scan of the abdomen revealed a uterus mass invading the right ureter, leading to ureterectasia and pyelectasis (Fig. 2). Ultrasonography of the thyroid bed and cervical node compartments showed no sign of recurrent tumor or locoregional metastases (Fig. 3). Cranial and chest CT, whole-body bone scans did not reveal further pathology. Laboratory test results revealed elevated carcinoembryonic antigen (CEA) 207.76 ng/ml (0.00–5.00), carbohydrate antigen 199 (CA199) 810.23 U/ml (0.00–37.00) and carbohydrate antigen 242(CA242) > 200 IU/ml (0.00–20.00) levels, normal T4, T3, thyroglobulin (TG) 0.129 ng/ml (1.400–78.000) and TSH 0.593 IU/L (< 1.750) levels.
On the patient’s symptom, medical history and examination results, the diagnosis of colon cancer metastases was established. Cytoreductive surgery was performed in January 2019 to rescue the right kidney from dysfunction. During the operation, hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed, with all other visible tumors including para-aortic lymph nodes, masses located on the abdominal wall, pelvic floor, diaphragmatic dome and ligamenta teres hepatis resected. Pathology revealed papillary thyroid cancer metastatic to one of the four para-aortic lymph nodes, with tumor cells that were positive for a panel of thyroid markers, including TG (Fig. 4), the rest three normal and metastatic colon cancer in the remaining resected tissues including uterus and accessories (Fig. 5). The patient recovered well post-operation and was administered 6 cycles of Folfiri chemotherapy (irinotecan, leucovorin and 5-fluorouracil) combined with bevacizumab. She developed lung metastasis and intra-abdominal relapse in July 2019. She was then treated with regorafenib, but died of progressive disease in December 2019.