Squamous Cell Carcinoma of Unknown Primary Presenting as a Mass in the Hepatic Flexure

Jessica S Crystal, MD1, Nisha Dhir, MD2. 1Rutgers-Robert Wood Johnson Medical School, 2University Medical Center of Princeton at Plainsboro

Primary Squamous cell carcinoma is commonly a disease process of the head, neck, lung, bronchus, cervix, uterus, anus, rectum, and skin, but at times, the site of primary disease is unknown. While there have been accounts of this disease process arising in the colon, few reports are published of it being found at the hepatic flexure.   Here we present a case of this disease entity which presented in a  79 year old female patient  who was found to be anemic with a hemogolobin of 8.3 on routine lab work.  Follow up diagnostic tests included a colonoscopy, during which a friable, fungating mass in the hepatic flexure was found. Pathology from this diagnostic procedure showed colonic mucosa with benign lymphoid aggregates.  Follow up CT scan of the abdomen/pelvis showed a mass lesion containing air in the right lobe of the liver inseparable from the hepatic flexure of the colon and the gallbladder, without other abnormalities. The patient then went for operative resection of this mass, but intraoperatively the 12 cm mass was found to be invading the right lobe of the liver, hepatic flexure, as well as the gallbladder, and could not be safely removed en bloc. The mass was biopsied then bypassed with an ileotransverse colostomy. Post-operative PET/CT showed intense activity in the large necrotic mass, a lymph node in the porta hepatis region, and a focus on the left adrenal gland.  Final pathology showed well-differentiated squamous cell carcinoma with extensive necrosis.  Tumor markers including Ca 19-9, CEA, and AFP were within normal limits.  The patient had an uncomplicated postoperative course, has been doing well on follow up visits, and has been seen by a medical oncologist for systemic therapy.  In conclusion, it is rare to find squamous cell carcinoma in the colon, particularly in the hepatic flexure, but when encountered a multi-disciplinary approach for treatment would be beneficial for the patient.

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