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Case History
Learning Objectives
Web References
Literature References
The patient is a 77 year old man. He lives in with his wife and he feels good today.
In 1994 he noted the appearance of a small amount of blood in the stool. This was red blood. His stool appeared normal in color. He was not straining at stool and had no abdominal pain. His appetite was good and he had no other symptoms. He initially felt that this would clear but it persisted. He would notice a small amount of blood almost everytime he moved his bowels. After about 1-2 months he went to the hospital, where he received his medical care, for evaluation of the rectal bleeding. He had a sigmoidoscopy which showed a large tumor. He underwent surgery in July of 1994. A small section of his sigmoid colon was removed. Pathology revealed a large sigmoid polyp, 1.5 x 2 cm. in size, which was almost obstructing the lumen of the colon. This was a benign tumor on microscopic examination.
However, following resection of the tumor, he still had rectal bleeding. He eventually underwent another sigmoidoscopy which showed an abnormal area of friable mucosa distal (closer to rectum) than his original lesion. This area narrowed his colon to about 70% of its original size. Biopsy showed colon cancer. He underwent another resection (see report). The patient was very depressed after he found out he had colon cancer and had a fear of dying. He had psychotherapy for this which helped the situation.
Since that time he has been followed with periodic colonoscopies as well as blood tests. A colonoscopy on August 12, 1998 resulted in a removal of a small cecal polyp 0.3 x 0.3 x 0.1 cm. This was a tubular adenoma microscopically. A colonoscopy prior to that on May 11, 1998 resulted in the removal of a diminutive polyp which was noted 95 cm. from the rectum. This lesion showed focal adenomatous change microscopically.
The patient has slightly modified his diet because of his surgery and treatment. He stays away from nuts and other foods that cause gas. For awhile he was on a high fiber diet but he did not like this. He has a problem with rectal leakage since the surgery which was felt to be due to damage to muscles and nerves at the time of surgery. At times he has to wear a sanitary pad to control the leakage. He occasionally has some diarrhea. However overall he feels good and he stays very active. He is very active in local veterans associations as well as the Bills booster club.
Several years ago his wife developed colon cancer. She underwent surgery but needed a colostomy for a short time after surgery and he helped care for her. Her tumor spread to her liver. She initially received chemotherapy, which did not work well, and is currently on herbal therapy and seems to be doing better. He has two daughters whom he has told should have colonoscopies to make sure that they are OK since they are at risk since both he and his wife have had colon cancer. One daughter, aged 54, just had a colonoscopy. His younger daughter has yet to have the procedure.
There is a family history of cancer. His father had lung cancer, as did a brother. Another brother had prostate cancer. There is no history of anyone in his family with colon cancer.
The patient talked a little bit about his diet since he has been married. Initially when they did not have much money they ate lots of lima beans and bacon. Later he ate a more regular diet, including roast beef. He also eats lots of vegetables, both cooked and raw, but doesn't eat much fruit. He used to drink about a liter of alcohol a week but stopped 5-6 years ago.
SURGICAL PATHOLOGY – NOV. 3, 1994
Gross Findings:
Received in formalin is a short segment of sigmoid colon measuring 5.5 cm. in length X
6.5-7.0 cm in circumference. The serosal surface is tan with the mesocolon measuring 2-3 cm in
thickness. It is opened revealing a tan prominently rugated surface with a broad based tumor
mass measuring 4.3 X 4.0 cm. The periphery of the tumor mass extends up to 1.0 cm from the
proximal resection margin and 0.5 cm from the distal resection margin. The central portion of
the tumor is deeply ulcerated. Sectioning reveals gray white tissue which appears to extend
through the wall and into the surrounding adipose tissues. Lymph nodes in the mesocolon
appear normal.
Microscopic Findings:
Discuss the epidemiology and risk factors for colorectal cancer including polyps as a risk factor.
Discuss treatments for colorectal cancer including surgical (when is colostomy required?), chemotherapy, and radiation and their side effects.
Diagnosis of colorectal cancer: Blood tests, physical exams, symptoms (signs), sphingmoidoscopy, colonoscopy (endoscopy), molecular screens for inherited varieties.
Prognosis assessment, staging. *Genetic factors including molecular genetic markers for inherited varieties. Possible approaches to gene therapy.
*Possibilities of colon cancer prevention: diet, fiber, aspirin, NSAIDS
Rajnish A. Gupta and Raymond N. DuBois
Aspirin, NSAIDs, and Colon Cancer Prevention: Mechanisms?
Gastroenterology 114: 1095 (1998)
Sidney J. Winawer, M.D. et. al.
Risk of Colorectal Cancer in the Families of Patients With Adenomatous Polyps
NEJM 334: 82 (1996)
Juul T. Wijnen, B.S., et al.
Clinical Findings with Implications for Genetic Testing in Families with Clustering
of Colorectal Cancer
NEJM 339: 511 (1998)
J. Milburn Jessup, M.D., et. al.
Diagnosing Colorectal Cancer: Clinical and Molecular Approaches
CA Cancer J. Clin. 47: 70 (1997)
Carlo Ratto, M.D., et. al.
Prognostic Factors in Colorectal Cancer
Dis. Colon Rectum 41: 1033 (1998)
K. S. Mainprize, et. al.
Early Colorectal Cancer: Recognition, Classification, and Treatment
Br. J. Surgery 85: 469 (1998)
A. G. Heriot and D. Kumar
Adjuvant Therapy for Resectable Rectal and Colonic Cancer
Br. J. Surgery 85: 300 (1998)
David Shibata, M.D., et. al.
The DCC Protein and Prognosis in Colorectal Cancer
NEJM 335: 1727 (1996)
Ralf M. Zwacka, Ph.D. and Malcolm G. Dunlop, M.D.
Gene Therapy for Colon Cancer
Hematology/Oncology Clinics of N. America 12: 595 (1998)