Introduction:

Colorectal cancer is one of the most prevalent malignancies worldwide, and its clinical suspicion is a major trigger for endoscopic evaluation. In advanced stages, liver metastases are frequently observed. However, the occurrence of synchronous metastases in the absence of signs, symptoms, or imaging findings suggestive of a primary lesion is uncommon, complicating the identification of the primary tumor and thus hindering appropriate treatment.

Case Presentation:

A 52-year-old male presented with abdominal pain in the epigastric and right hypochondriac regions, accompanied by weight loss and postprandial distress. On physical examination, a palpable mass was noted in the left upper quadrant. Upper gastrointestinal endoscopy revealed extrinsic gastric compression. A contrast-enhanced abdominopelvic CT scan showed a large hepatic lesion with multiple satellite nodules, but no evidence of a primary lesion. A liver trucut biopsy was performed, revealing features consistent with colorectal adenocarcinoma, confirmed by immunohistochemistry. Colonoscopy identified a lesion in the sigmoid colon. The patient was referred to the oncology department and treated with a FOLFOXIRI + Avastin regimen for six months, resulting in clinical, imaging, and endoscopic improvement.

Conclusions:

In the diagnostic approach to colorectal cancer, clinical and paraclinical findings typically guide the use of endoscopic and screening tools. In their absence, particularly in the presence of hepatic lesions, liver biopsy should be considered to expedite diagnosis and enable timely, targeted therapy.