Atypical Presentation of Colon Adenocarcinoma: A Case Report
Atypical Presentation of Colon Adenocarcinoma: A Case Report
A 27-year-old man from Kampala, Uganda, presented with a three-month history of progressive abdominal swelling and discomfort to our hospital three years ago. He was well until three months prior to admission; he developed fever, malaise, and drenching night sweats and noticed a progressive loss of weight. He did not have vomiting, diarrhea, or yellow eyes. An examination of his other systems revealed no other relevant findings. His medical and surgical history was unremarkable. He was a student and did not consume alcohol or smoke.
During an examination, he was sick-looking and wasted and had a body mass index of 20. He had no lymphadenopathy or stigmata of liver disease, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), lymphoma, or any mucocutaneous abnormalities. The results of an abdominal examination were remarkable for ascites as evidenced by shifting dullness. The results of a rectal examination were reported as normal. The results of the rest of his physical examination were also normal. He was worked up for his ascites and wasting.
Routine diagnostic paracentesis and evaluation of the ascitic fluid were done while our patient was awaiting ultrasonography. A straw-colored, slightly blood-stained fluid showed total protein of 4.2 g/dL, glucose of 80 mg/dL, total white cell count of 30,000 cells/mm, white cell differential counts were as follows: neutrophils 24% and lymphocytes 76%. Gram and Ziehl-Neelsen stains were negative, the serum-ascites-albumin gradient was less than 1.1, and ascitic protein was more than 2.5 g/dL. These findings pointed toward a peritoneal pathology, probably malignancy of the peritoneum.
An abdominal ultrasound confirmed gross ascites. The peritoneum was markedly thickened, nodular, and irregular with areas of cystic change and involvement of the omentum. The liver, spleen, and kidneys appeared normal. There were no features of enlarged lymph nodes.
A barium meal examination showed a transverse ulcer in the sigmoid colon and thickened loops. Later, a lower gastrointestinal tract flexible sigmoidoscopy showed an extrinsic mass protruding from the anterior wall of the rectum, which was irregular during a rectal examination. A large polyp was seen in the sigmoid colon and a biopsy was taken and sent for histopathology.
A chest X-ray was normal. A hematological evaluation was normal except for a mild thrombocytosis of 550,000/mm and an erythrocyte sedimentation rate of 90 mm/hour. The results of serum biochemical tests were normal. Screenings for HIV and hepatitis B were negative. The results of a routine stool examination were also normal.
A histopathological analysis of cell blocks made from the sediment of cytospun ascitic fluid and a sigmoid colon polyp obtained at sigmoidoscopy revealed atypical, malignant, deeply basophilic epithelial glands suggestive of adenocarcinoma (Figure 1A). An alcian blue/periodic acid Schiff and mucicarmine staining was positive for neutral mucin, which stained magenta, confirming mucinous adenocarcinoma (Figure 2A, B).
(Enlarge Image)
Figure 1.
(A) Hematoxylin and eosin staining of cell block shows a colloid carcinoma with malignant mucin-filled epithelial cells floating free in mucinous pools. (B) Immunohistochemistry staining using CDX2 is strongly positive in colorectal carcinoma.
(Enlarge Image)
Figure 2.
(A) Mucicarmine staining shows epithelial strips floating in mucin, which stains red. (B) Alcian blue/periodic acid Schiff stains neutral mucin magenta.
For staging purposes, abdominal computed tomography (CT) was done. Pre- and post-contrast axial CT scans of the abdomen were done at 7 mm-thick slices. They showed extensive multiloculated hypodense cystic areas in the peritoneal cavity with the largest loculi measuring 152 × 123 × 263 mm. The liver was enlarged but was free of focal masses. The spleen, kidneys, and urinary bladder were normal. Some of the intestinal loops were thickened. The retroperitoneal areas appeared normal. There were features of extensive multiloculated ascites with hepatomegally. No other abdominal masses were seen.
Cytoreductive abdominal surgery revealed a bulky copious mucinous gelatinous tumor filling the abdominal cavity making detailed examination and resection difficult. Therefore, a sample was taken for cytopathological examination and it corroborated the previous finding of mucinous adenocarcinoma. Immunohistochemistry was done at the Fuerth Teaching Hospital at the University of Erlangen (Germany). Staining with CDX2 showed strong positivity, confirming our suspicion of a primary colon tumor (Figure 1B).
Our patient had initially received a two-week therapeutic trial for tuberculosis with a drug regimen of rifampicin, isoniazid, ethambutol, and pyrazinamide. This treatment was discontinued when the diagnosis of adenocarcinoma was made.
Tumor staging revealed advanced disease and palliative care, which included counseling, frequent abdominocentesis and pain management with oral morphine, was given. Our patient died of the disease.
During the autopsy, a general examination revealed severe cachexia and marked abdominal distension. After a midline abdominal incision was made, a mucinous gelatinous hemorrhagic tumor surrounding all of the abdominal organs and infiltrating the diaphragm was seen. On closer examination, the tumor was seen to be emanating from the sigmoid colon and was tightly adherent to the rest of the colon and other abdominal viscera (Figure 3A). Further colonic dissection revealed multiple ulcerated and necrotic polyps 2 mm to 3 mm in diameter in the sigmoid colon. A histopathological examination of these polyps revealed a pseudostratified glandular epithelium with marked cellular atypia and a papillary pattern (Figure 3B).
(Enlarge Image)
Figure 3.
(A) At autopsy, mucinous gelatinous polypoid masses arising from the sigmoid colon and covering the serosa are seen. (B) Hematoxylin and eosin staining of the masses in (A) showed an invasive well-differentiated adenocarcinoma.
Case Presentation
A 27-year-old man from Kampala, Uganda, presented with a three-month history of progressive abdominal swelling and discomfort to our hospital three years ago. He was well until three months prior to admission; he developed fever, malaise, and drenching night sweats and noticed a progressive loss of weight. He did not have vomiting, diarrhea, or yellow eyes. An examination of his other systems revealed no other relevant findings. His medical and surgical history was unremarkable. He was a student and did not consume alcohol or smoke.
During an examination, he was sick-looking and wasted and had a body mass index of 20. He had no lymphadenopathy or stigmata of liver disease, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), lymphoma, or any mucocutaneous abnormalities. The results of an abdominal examination were remarkable for ascites as evidenced by shifting dullness. The results of a rectal examination were reported as normal. The results of the rest of his physical examination were also normal. He was worked up for his ascites and wasting.
Routine diagnostic paracentesis and evaluation of the ascitic fluid were done while our patient was awaiting ultrasonography. A straw-colored, slightly blood-stained fluid showed total protein of 4.2 g/dL, glucose of 80 mg/dL, total white cell count of 30,000 cells/mm, white cell differential counts were as follows: neutrophils 24% and lymphocytes 76%. Gram and Ziehl-Neelsen stains were negative, the serum-ascites-albumin gradient was less than 1.1, and ascitic protein was more than 2.5 g/dL. These findings pointed toward a peritoneal pathology, probably malignancy of the peritoneum.
An abdominal ultrasound confirmed gross ascites. The peritoneum was markedly thickened, nodular, and irregular with areas of cystic change and involvement of the omentum. The liver, spleen, and kidneys appeared normal. There were no features of enlarged lymph nodes.
A barium meal examination showed a transverse ulcer in the sigmoid colon and thickened loops. Later, a lower gastrointestinal tract flexible sigmoidoscopy showed an extrinsic mass protruding from the anterior wall of the rectum, which was irregular during a rectal examination. A large polyp was seen in the sigmoid colon and a biopsy was taken and sent for histopathology.
A chest X-ray was normal. A hematological evaluation was normal except for a mild thrombocytosis of 550,000/mm and an erythrocyte sedimentation rate of 90 mm/hour. The results of serum biochemical tests were normal. Screenings for HIV and hepatitis B were negative. The results of a routine stool examination were also normal.
A histopathological analysis of cell blocks made from the sediment of cytospun ascitic fluid and a sigmoid colon polyp obtained at sigmoidoscopy revealed atypical, malignant, deeply basophilic epithelial glands suggestive of adenocarcinoma (Figure 1A). An alcian blue/periodic acid Schiff and mucicarmine staining was positive for neutral mucin, which stained magenta, confirming mucinous adenocarcinoma (Figure 2A, B).
(Enlarge Image)
Figure 1.
(A) Hematoxylin and eosin staining of cell block shows a colloid carcinoma with malignant mucin-filled epithelial cells floating free in mucinous pools. (B) Immunohistochemistry staining using CDX2 is strongly positive in colorectal carcinoma.
(Enlarge Image)
Figure 2.
(A) Mucicarmine staining shows epithelial strips floating in mucin, which stains red. (B) Alcian blue/periodic acid Schiff stains neutral mucin magenta.
For staging purposes, abdominal computed tomography (CT) was done. Pre- and post-contrast axial CT scans of the abdomen were done at 7 mm-thick slices. They showed extensive multiloculated hypodense cystic areas in the peritoneal cavity with the largest loculi measuring 152 × 123 × 263 mm. The liver was enlarged but was free of focal masses. The spleen, kidneys, and urinary bladder were normal. Some of the intestinal loops were thickened. The retroperitoneal areas appeared normal. There were features of extensive multiloculated ascites with hepatomegally. No other abdominal masses were seen.
Cytoreductive abdominal surgery revealed a bulky copious mucinous gelatinous tumor filling the abdominal cavity making detailed examination and resection difficult. Therefore, a sample was taken for cytopathological examination and it corroborated the previous finding of mucinous adenocarcinoma. Immunohistochemistry was done at the Fuerth Teaching Hospital at the University of Erlangen (Germany). Staining with CDX2 showed strong positivity, confirming our suspicion of a primary colon tumor (Figure 1B).
Our patient had initially received a two-week therapeutic trial for tuberculosis with a drug regimen of rifampicin, isoniazid, ethambutol, and pyrazinamide. This treatment was discontinued when the diagnosis of adenocarcinoma was made.
Tumor staging revealed advanced disease and palliative care, which included counseling, frequent abdominocentesis and pain management with oral morphine, was given. Our patient died of the disease.
During the autopsy, a general examination revealed severe cachexia and marked abdominal distension. After a midline abdominal incision was made, a mucinous gelatinous hemorrhagic tumor surrounding all of the abdominal organs and infiltrating the diaphragm was seen. On closer examination, the tumor was seen to be emanating from the sigmoid colon and was tightly adherent to the rest of the colon and other abdominal viscera (Figure 3A). Further colonic dissection revealed multiple ulcerated and necrotic polyps 2 mm to 3 mm in diameter in the sigmoid colon. A histopathological examination of these polyps revealed a pseudostratified glandular epithelium with marked cellular atypia and a papillary pattern (Figure 3B).
(Enlarge Image)
Figure 3.
(A) At autopsy, mucinous gelatinous polypoid masses arising from the sigmoid colon and covering the serosa are seen. (B) Hematoxylin and eosin staining of the masses in (A) showed an invasive well-differentiated adenocarcinoma.
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