Case Report

Aggressive Combined Modality Therapy for

Recurrent Colorectal Cancer Involving the
Duodenum and Pancreas: A Report of 5 Cases
Michael J. Overman,1 David Fogelman,1 Aref Al-Kali,2 Christopher H. Crane,3
Douglas Evans,4 Eddie K. Abdalla,4 Peter Pisters,4 Scott Kopetz,1
Cathy Eng,1 Robert A. Wolff1
Abstract
We report 5 cases in which the recurrence of colorectal cancer (CRC) presented as a mass involving the duodenum
and pancreas. The treatment approach for such recurrences is not standardized, and in particular, the benets of pan-
creaticoduodenectomy for such cases are not known. We describe the successful use of aggressive multimodality
treatment with chemotherapy, radiation, and en bloc surgical resection. Such trimodality therapy can result in durable
palliation of symptoms and long-term survival for patients with recurrent CRC involving the duodenum and pancreas,
even when other metastases are present.

Clinical Colorectal Cancer, Vol. 7, No. 5, 338-342, 2008; DOI: 10.3816/CCC.2008.n.045

Keywords: Adenocarcinoma, Capecitabine, Pancreaticoduodenectomy, Relapse, Resection, Trimodality

Introduction creaticoduodenectomy.5-7 Though much rarer, recurrent CRC involv-

For locally advanced colorectal cancers (CRCs) that invade or
adhere to adjacent organs or structures, en bloc resection of all
involved structures is considered the standard of care. For example, in
cases of locally recurrent rectal cancer, aggressive surgery, often requir-
ing pelvic exenteration, is considered the standard of care, particularly
when negative resection margins are achievable.1,2 In addition, resec-
tion of metastatic deposits in the liver or lung has demonstrated clear
improvements in survival, with curative potential.3,4
Given the close anatomic relationship between the hepatic flexure,
the second portion of the duodenum, and the head of the pancreas,
invasion of these sites by a locally advanced right-side colon cancer is
not uncommon. Case series of patients with colonic tumors invading
the pancreas and duodenum at initial presentation have suggested
improved survival with aggressive en bloc resections that include pan-
1Department of Gastrointestinal Medical Oncology
The University of Texas M. D. Anderson Cancer Center, Houston
2MedicalOncology/Hematology Fellowship, Oklahoma University, Oklahoma City
3Department of Radiation Oncology
4Department of Surgical Oncology
The University of Texas M. D. Anderson Cancer Center, Houston
Submitted: Mar 26, 2008; Revised: May 20, 2008; Accepted: Jun 23, 2008
Address for correspondence: Michael J. Overman, MD, M. D. Anderson Cancer
Center, Unit 426, 1515 Holcombe Blvd, Houston, TX 77005
Fax: 713-745-1163; e-mail: moverman@mdanderson.org
ing the duodenum and pancreas can result from a local recurrence of
a right-sided colon cancer, extension from neighboring lymph nodes,
or hematogenous metastasis.8,9 At present, the therapeutic paradigm
for recurrent colon cancer involving the duodenum and pancreas is
not well defined.
In this case series, we present 5 cases treated at The University
of Texas M. D. Anderson Cancer Center (MDACC). Information
regarding these 5 cases was obtained under an institutional review
boardapproved protocol and represents a collection of selected
cases evaluated at MDACC from 2001 to 2005. These cases illus-
trate the biologic mechanisms of recurrence at the duodenal and
pancreatic interface and demonstrate the potential role of aggressive
multimodality intervention.
Case 1
In 1991, a 61-year-old man underwent low anterior resection
for a T3 N0 M0 rectal adenocarcinoma. Surgery was followed
by adjuvant therapy with 5-fluorouracil (5-FU) and radiation. In
2000, the patient underwent surgical resection of a rectal cancer
metastasis to the right lung and subsequently received 6 months of
postoperative 5-FU therapy.
In January 2001, the patient developed gastrointestinal bleeding,
and esophagogastroduodenoscopy (EGD) revealed a duodenal ulcer.
Biopsy of this ulcer demonstrated adenocarcinoma. The patient was
referred to MDACC, where computed tomography (CT) of the abdo-

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338 Clinical Colorectal Cancer September 2008

men and pelvis revealed the presence of nonspecific duodenal wall
thickening without other evidence of metastatic disease. Subsequent
positron emission tomography demonstrated a hypermetabolic focus
at the duodenum with no other sites of abnormal uptake detected.
After multidisciplinary treatment planning, he received concurrent
5-FU and external-beam radiation therapy (EBRT) followed by a
pancreaticoduodenectomy. Pathology showed that the adenocarci-
noma was moderately differentiated and had invaded through the
muscularis propria into the underlying pancreas. No cancer was
found in 5 resected lymph nodes. Immunohistochemical (IHC)
analysis revealed a cytokeratin (CK) 20positive and CK7-negative
immunophenotype and had similar morphology in comparison with
the patients previous rectal cancer.
In August 2002, an isolated lung metastasis was discovered and
resected. A second lung metastasis was resected in March 2003, but
by July 2003, two and a half years after the diagnosis of his duode-
nal recurrence, the patient was noted to have multifocal metastatic
disease. He subsequently received irinotecan- and oxaliplatin-based
systemic chemotherapy regimens. The patient died of metastatic dis-
ease in November 2006, approximately 70 months after the initial
diagnosis of metastatic disease to the duodenum.
Case 2
In 1995, a 67-year-old man underwent a right hemicolectomy
and 1 year of adjuvant 5-FU therapy for a T3 N2 M0 well-dif-
ferentiated adenocarcinoma of the cecum. In February 2004, he
presented with partial gastric outlet obstruction. Computed tomog-
raphy imaging revealed an 8-cm mesenteric mass involving the site
of his previous right hemicolectomy with adjacent invasion of the
head of the pancreas and proximal duodenum. Endoscopic biopsy
confirmed adenocarcinoma. He underwent a gastrojejunostomy for
relief of his duodenal obstruction and shortly thereafter underwent
combined-modality therapy with capecitabine and EBRT. In June
2004, the patient underwent a pancreaticoduodenectomy with en
bloc resection of the transverse colon and distal small bowel, as
well as extended retroperitoneal and mesenteric lymphadenectomy.
Pathologic evaluation revealed foci of well-differentiated adenocar-
cinoma involving the ileocolic anastomosis, duodenum, pancreas,
and surrounding fibroadipose tissue that was morphologically con-
sistent with a colonic adenocarcinoma. Additionally, 6 of 14 lymph
nodes were positive. Because of the patients previous long disease-
free interval (DFI), he was followed expectantly. In May 2007, the
patient developed a solitary pulmonary metastasis with a biopsy
demonstrating caudal-related homeobox 2positive, CK20-posi-
tive, and CK7-negative adenocarcinoma consistent with a colonic
primary. He received 3 cycles of oxaliplatin-based therapy followed
by lung resection. At last follow-up (48 months after the initial
recurrence), the patient is alive and without evidence of disease.
Case 3
In May 1997, a 51-year-old man underwent a right hemicolec-
tomy for a poorly differentiated T3 N2 M0 adenocarcinoma of
the cecum, followed by 1 year of adjuvant therapy with 5-FU. In
February 2000, he underwent bilateral pulmonary wedge resections
for metastases, followed by 4 months of adjuvant therapy with
5-FU and irinotecan.
In November 2000, the patient developed epigastric discom-
fort and persistent nausea. Endoscopic duodenal biopsies revealed
adenocarcinoma, but no definitive mass was observed on CT scans.
Systemic chemotherapy with 5-FU was initiated, and repeat imaging
in June 2001 revealed a 4-cm mass lateral to the second portion of
the duodenum and anterior to the midportion of the right kidney.
Combination therapy with capecitabine and radiation was given,
followed by therapy with capecitabine alone. In April 2002, the
patient developed locally progressive disease with partial gastric outlet
obstruction from duodenal narrowing. Despite the presence of low-
volume lung metastases, he underwent a pancreaticoduodenectomy
with en bloc resection of the distal ileum, proximal transverse colon,
and right kidney. Pathologic evaluation revealed a 4-cm moderately
differentiated adenocarcinoma involving the duodenum, head of
the pancreas, and serosa of the ileocolic anastomosis. Additionally, 2
of 16 lymph nodes examined were involved. Comparison with the
patients previous tumor revealed a similar morphology and an identi-
cal CK20-positive, CK7-negative IHC phenotype.
Pulmonary metastases slowly progressed, and he received sev-
eral investigational treatments, none of which led to an objective
response. In January 2004, he started treatment with irinotecan and
oxaliplatin for progressive lung and retroperitoneal disease. He died
in January 2005, approximately 50 months after treatment for the
recurrence involving the pancreas and duodenum.
Case 4
In October 2003, a 59-year-old man underwent a right hemicolec-
tomy and anterior duodenal wall resection for a T4 N1 M0 adenocar-
cinoma of the hepatic flexure. Pathology revealed a moderately differ-
entiated colonic adenocarcinoma with invasion through the colonic
wall and into the periduodenal fibroadipose tissue. Additionally, 1 of
16 lymph nodes examined was positive. The surgical margin status
could not be definitively determined because of specimen fragmenta-
tion. The patient received 9 months of adjuvant therapy with 5-FU.
In August 2004, the patient developed right-side abdominal pain,
nausea, and vomiting. Computed tomography showed a mass in the
second portion of the duodenum that had invaded the pancreas and
was obstructing the biliary and pancreatic ducts. Esophagogastrodu
odenoscopy revealed a large, partially obstructing ulcerative mass in
the duodenum with an endoscopic biopsy, demonstrating moderately
differentiated adenocarcinoma. Analysis of the original tumor speci-
men and recurrent tumor specimen revealed microsatellite instability
with loss of human mutL homolog 1 expression and a focal CK7-
positive and CK20-negative staining pattern.
The patient underwent a biliary bypass and palliative gastroje-
junostomy, followed by combination therapy with capecitabine
and radiation. After a stable response to this therapy, the patient
was presented at a multidisciplinary conference, and because of
poor nutritional status, surgical resection was not recommended.
He subsequently developed progressive metastatic disease and died
14 months after recurrence.
Case 5
In 1999, a 66-year-old man was diagnosed with a T3 N1 M0
colonic adenocarcinoma of the hepatic flexure. Adjuvant therapy with
5-FU was given for 6 months.
Clinical Colorectal Cancer September 2008 339
 Treatment for Recurrent Colorectal Cancer Involving the Duodenum and Pancreas

Table 1 Summary of Five Cases of Recurrent Colorectal Cancer Involving the Duodenum and Pancreas
Overall
Age Primary Initial Time to
Case Pathology Mode of Other Sites Survival
(Years) Location Stage Recurrence Symptoms Treatment
Recurrence of Disease* Status
(Months)
(Months)
Moderately None
Neoadjuvant 5-FU/Xrt and Hematogenous (previous lung
1 61 Rectal T3 N0 115 Bleeding differentiated 70 (Dead)
pancreaticoduodenectomy adenocarcinoma metastasis metastasis)
Nausea, Neoadjuvant capecitabine/Xrt Well-differentiated Local None
2 67 Cecum T3 N2 103 48 (Alive)
vomiting and pancreaticoduodenectomy adenocarcinoma recurrence
Poorly None
Pain, nausea, Neoadjuvant capecitabine/Xrt Local
3 51 Cecum T3 N2 42 differentiated (previous lung 50 (Dead)
vomiting and pancreaticoduodenectomy recurrence
adenocarcinoma metastases)
Moderately
Pain, nausea, Local
4 59 Right colon T4 N1 10 Capecitabine/Xrt differentiated None 14 (Dead)
vomiting adenocarcinoma recurrence

Poorly
Lymphatic Liver and
5 66 Right colon T3 N1 46 Pain Capecitabine/oxaliplatin differentiated 6 (Dead)
adenocarcinoma metastasis lung

*Attime of duodenal recurrence.

From duodenal recurrence.
Abbreviations: 5-FU = 5-fluorouracil; Xrt = radiation therapy

In May 2003, the patient reported weight loss and vague abdominal
pain. Computed tomography revealed a 6-cm peripancreatic mass
with invasion into the pancreas and duodenum. The patient also had
retroperitoneal and mesenteric lymphadenopathy, liver metastases,
and lung metastases. Esophagogastroduodenoscopy revealed a duode-
nal mass, which pathology confirmed was adenocarcinoma. Review of
his duodenal pathology specimen at MDACC showed that the tumor
was a poorly differentiated CK20-positive and CK7-negative adeno-
carcinoma. The patient was presented to a multidisciplinary confer-
ence, and considering his cytokeratin staining pattern and extensive
ileocolic mesenteric adenopathy, the patient was determined to have
recurrent colon cancer, with the peripancreatic mass representing a
large nodal mass.
Despite treatment with capecitabine and oxaliplatin, the patient
died in December 2003, 7 months after the recurrence.
Results
The time from initial diagnosis of colon or rectal cancer to recurrence
in our series ranged from 6 months to 10 years. All patients initially
had localized disease treated with surgery and adjuvant chemotherapy
with or without radiation therapy. The most common presenting
symptoms of recurrence at the duodenal-pancreatic interface were pain,
nausea, and vomiting. In all cases, pathologic evaluation conducted
at MDACC determined that the recurrence was an adenocarcinoma
consistent with a colorectal primary tumor. Comparison with the
patients primary tumor was performed in 3 cases (cases 1, 3, and 4).
No coexisting adenoma or dysplasia was present to suggest a duodenal
primary tumor in any case.
In these 5 cases, evaluation with EGD or CT (and usually both)
demonstrated the presence of recurrent disease. Pathologic diagnosis of
recurrence was made by endoscopic duodenal biopsy in all patients. All
cases presented with involvement of the pancreas and second portion of
the duodenum. Lymph node involvement at the initial CRC diagnosis
was present in 4 cases, whereas direct duodenal invasion was present in
only 1 case. The surgical margins from the initial CRC resection were
negative in each case except case 4, in which the margin status could
not be determined.
The mechanism of recurrence was thought to be by direct exten-
sion in 3 patients, hematogenous spread in 1 patient, and lymphatic
spread in 1 patient (Table 1). Three patients underwent aggressive
trimodality treatment, with a resulting mean survival of 56 months.
Of these 3 cases, patient 2 remains alive without evidence of disease
recurrence at last follow-up (48 months after recurrence), while
patients 1 and 3 died of disease at 70 and 50 months, respectively,
after their duodenal recurrence. These impressive survival results
were observed despite both patients having a history of previous
pulmonary metastases. All 3 patients who underwent pancreati-
coduodenectomy experienced durable relief from their presenting
symptoms of bleeding, as in patient 1, or duodenal obstruction,
as in patients 2 and 3. The 2 patients who did not have surgical
resection of their duodenal recurrence survived for 6 months and
14 months, respectively, after the diagnosis of recurrence.
Discussion
Adenocarcinoma involving the duodenum and pancreas can result
from primary duodenal adenocarcinoma, primary pancreatic adeno-
carcinoma, metastatic disease, or local invasion by adenocarcinoma
originating in neighboring organs. Differentiating between these
various situations requires thorough pathologic analysis and high-qual-
ity radiologic imaging. In particular, making a distinction between
adenocarcinomas of the small bowel and colon is often difficult. A
study examining the use of CK7 and CK20 to distinguish small
bowel adenocarcinoma from colorectal adenocarcinoma found that, of
24 small-intestine adenocarcinomas, CK7 and CK20 were expressed
in 100% and 67%, respectively.10 Of the 23 CRC cases in the study,
CK7 was expressed in 4%, and CK20 was expressed in 95%. However,
a recent study examining 486 carcinomas of the digestive system found
far fewer discernable differences in CK7 and CK20 expression levels.11

340 Clinical Colorectal Cancer September 2008

 Michael J. Overman et al

Table 2 Reported Cases of Relapsed Colorectal Cancer Involving the Duodenum and Pancreas
Primary Time to Recurrence Other Sites Overall Survival
Study Year Treatment Survival Status
Location (Months) of Disease* (Months)
Kamal et al6 2003 Rectum 48 None Duodenal resection 10 Alive
Right colon 48 None Pancreaticoduodenectomy 31 Alive
Sperti et al28 2003 Colon Synchronous Colon Pancreaticoduodenectomy 28 Alive
Right colon 10 None Pancreaticoduodenectomy 17 Dead
Ascending colon 42 None Pancreaticoduodenectomy 20 Alive
Wagle et al29 2001
Hepatic flexure 18 None Pancreaticoduodenectomy 4 Alive
Le Borgne et al30 2000 Colon 6 None Pancreaticoduodenectomy 12 Dead
Yoshimi et al31 1999 Ascending colon 36 None Pancreaticoduodenectomy 24 Dead
Right colon 15 NR Pancreaticoduodenectomy 41 Dead
Harrison et al27 1997
Right colon 15 NR Pancreaticoduodenectomy 21 Dead
Colon 34 None Pancreaticoduodenectomy 43 Alive
Nakeeb et al32 1995
Colon 14 None Pancreaticoduodenectomy 24 Dead
Alfonso et al5 1979 Hepatic flexure 17 None Pancreaticoduodenectomy 12 Alive

*Attime of duodenal recurrence.

From duodenal recurrence.
Attime of publication.
Abbreviation: NR = not reported

Of the 23 small intestine adenocarcinomas and 68 colorectal adeno-
carcinomas, CK7 was expressed in 34% and 10%, respectively, while
CK20 was expressed in 47% and 76%, respectively. Case 4, which
demonstrated a CK20-negative and focal CK7-positive expression
pattern, reflects the CK pattern frequently observed in patients with
microsatellite-unstable colon adenocarcinomas.12
Involvement of the duodenum and pancreas by locally recurrent
CRC is most commonly associated with a right-sided colon cancer,
as seen in cases 2, 3, and 4. This is because the hepatic flexure of the
colon is tightly affixed to the infra-ampullary portion of the descend-
ing duodenum by the transverse mesocolon.13 In addition, invasion
from the periduodenal and peripancreatic lymph nodes can result in
involvement of the duodenum and pancreas, as seen in case 5. The
lymphatic drainage from the cecum and ascending colon follows the
ileocolic vessels toward the root of the superior mesenteric artery and
vein, adjacent to the duodenum and pancreas. A previous study has
reported 8 cases in which pancreatic involvement from right-side colon
cancer were localized to the pancreatic head.14 This involvement was
believed to result from local peripancreatic nodal invasion in 3 cases,
from invasion by a paraduodenal mass in 1 case, and from metastatic
disease in 4 cases.
Metastases to the duodenum and pancreas are rare, with autop-
sy series reporting small-intestinal metastases in approximately
2%-4% of all cancer cases and pancreatic metastases in approximately
4%-15%.8,9,15-17 Involvement of the pancreas by primary CRCs has
been reported in 2%-7% of cases described in autopsy series.16,17 In
general, these metastases are components of widespread metastatic dis-
ease, and the frequency of solitary metastases to these sites is unknown.
Tumors that most commonly metastasize to the pancreas are those
of the lung, stomach, and kidney. For small-intestinal metastases, the
most common primary tumors are melanoma, lung cancers, and breast
cancers.8,18-20 In 2 autopsy series in which involvement by peritoneal
carcinomatosis and direct extension were excluded, the rate of CRC
involvement of the small intestine was 2%-3%.21 Hematogenous
spread was the modality of recurrence for the patient in case 1, who
initially presented with a primary tumor in the rectum.
The use of pancreaticoduodenectomy for patients with colon
cancer who initially present with pancreatic and duodenal involve-
ment has been described in case series from MDACC and
Memorial Sloan-Kettering Cancer Center (MSKCC).22,23 In the
MDACC series, 7 patients with duodenum or pancreatic head
invasion by colon cancer underwent a pancreaticoduodenectomy.
The median overall survival (OS) was 32 months, with no opera-
tive or postoperative deaths. In the series from MSKCC, 8 patients
with right-sided colon cancer involving the duodenum or pancreas
underwent pancreaticoduodenectomy or duodenectomy. No post-
operative deaths occurred, and 6 patients were alive without disease
recurrence at a median follow-up time of 26 months.
Numerous small case series also describe the use of pancre-
aticoduodenectomy for the treatment of patients with metastatic
disease involving the pancreas. However, the vast majority of these
studies report outcomes for patients with multiple primary tumor
types, with the predominant tumor being renal cell carcinoma.24,25
The Fox Chase Cancer Center has reported the outcomes for
18 patients, 8 with colon cancer, who had locally recurrent upper
abdominal cancers that involved the pancreas.26 All patients under-
went a pancreatic resection, with all 8 patients with colon cancer
requiring a pancreaticoduodenectomy. The median OS for all
18 patients was 46 months. In addition, investigators from MSKCC
reported a series of 18 patients who underwent pancreaticoduode-
nectomy for isolated metastatic or locally advanced nonperiampullary
cancers.27 The median OS was 40 months. There was no significant
difference in survival between the subgroup of patients with direct
invasion (8 cases) and the subgroup of patients with metastatic or

Clinical Colorectal Cancer September 2008 341

 Treatment for Recurrent Colorectal Cancer Involving the Duodenum and Pancreas
locally recurrent disease (10 cases). The primary tumor types in these
18 patients comprised 7 colon cancers, 4 gastric cancers, 3 renal cell
cancers, 2 lung cancers, 1 bladder cancer, and 1 melanoma.
From the literature, individual patient data are available for
13 patients who underwent surgical resection of recurrent or metastat-
ic CRC involving the pancreas and duodenum (Table 2).5,6,27-32 The
majority of these recurrences were from adenocarcinomas of the right
colon (12 of 13). The mean OS for these 12 cases was 24 months.
In our series, the mean OS for all 5 patients was 38 months. For
the 3 patients who underwent aggressive multimodality treatment
with resection, chemotherapy, and radiation therapy, the OS was
48 months, 50 months, and 70 months, respectively. These 3 patients
represent a highly selected group, with 2 patients demonstrating pro-
longed DFIs from initial diagnosis of > 8 years.
At MDACC, we often favor the delivery of chemoradiation before
surgical resection in patients with localized recurrences. This approach
allows for a reduction in the tumor burden before a planned surgi-
cal intervention. In addition, preoperative radiation therapy, which
is delivered when blood flow and oxygenation are unimpaired by
postsurgical changes, might have an improved benefit-to-risk ratio
compared with postoperative radiation therapy. An important benefit
of this approach is improved patient selection for an aggressive surgical
intervention. If, during neoadjuvant therapy, local tumor progression
or new metastatic disease develops, inappropriate surgical intervention
might then be avoided, as in case 4. In the 3 patients who ultimately
underwent pancreaticoduodenectomy, the intervals between initial
diagnosis of duodenal relapse and surgical resection were 4, 5, and 7
months, respectively.
There are limitations to the interpretation of our findings. As a ret-
rospective case series, there is the potential for selection and interpreta-
tion bias. Because of the aggressive nature of the treatment discussed in
this report, patients who underwent multimodality therapy represent
a heavily selected group. The selection of such patients for aggressive
therapy, as represented in our report, should be made by an integrated
multidisciplinary team, and the applicability of our treatment approach
to other medical settings without multidisciplinary cancer care might
not be appropriate.
Conclusion
This case series and literature review suggests that selected patients
with CRC with relapsed disease involving the duodenum and pan-
creas can achieve long-term palliation of symptoms and prolonged
survival with a pancreaticoduodenectomy. Our experience suggests
that the best outcomes appear to be obtained through a multimodal-
ity therapy approach.
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