Unusual sized cecal mass presenting without obstruction: a case report
© Elyassi et al; licensee BioMed Central Ltd. 2009
Received: 06 November 2008
Accepted: 06 February 2009
Published: 06 February 2009
Colorectal cancer (CRC) is a common and lethal disease with thousands of new cases of large bowel cancer diagnosed in the United States each year. Colorectal cancer frequently causes obstruction of the large bowel. Cases of obstructions and perforations have been documented with masses well below 6 cm in diameter. Obstruction and/or perforation are important predictors of prognosis with respect to colorectal carcinomas.
The following is the presentation of an unusual case of a 13 × 12 × 16 cm colonic adenocarcinoma without any signs of obstruction or perforation.
Perioperative mortality rates for colorectal cancer with obstruction have been documented anywhere from 5% to 47.6%, making obstruction an important predictive factor in long-term patient survival. Although a correlation between obstruction and patient outcome has been determined, a correlation between colorectal tumor size/staging and obstruction has yet to be investigated.
Colorectal cancer (CRC) is a common and lethal disease with over 150,000 new cases of large bowel cancer diagnosed each year in the United States. In the U.S., obstruction of the large bowel is most frequently caused by colorectal cancer. Bowel obstruction occurs when the normal flow of bowel contents is interrupted. Small bowel obstruction in patients with cancer is a common and difficult problem and has been described in up to 28 percent of patients with colorectal carcinoma. In a study by Maurer, CA et al, of 69 patients with large bowel obstruction, 38 percent were associated with colorectal carcinoma. Cases of obstructions and perforations have been documented with masses well below 6 cm in diameter. The following is the presentation of an unusual case of a 13 × 12 × 16 cm colonic adenocarcinoma without any signs of obstruction or perforation.
A 58 year old Caucasian male with a history of iron deficiency anemia and severe depression presented with weakness and shortness of breath, along with a loss of appetite and thirty pound weight loss. He also has a long history of psychological issues, including extensive illicit drug use, bipolar personality disorder, anxiety, chronic depression, and suicidal tendencies. He denied any constipation, diarrhea, tenesmus, melena, hematochezia, nausea, vomiting, or abdominal pain. He did, however, report feeling a firm mass in his right upper and lower abdominal quadrants, which he claims has grown in size over the years.
Upon physical examination, the patient was found to appear thin, pale, but comfortable. He was found to have normal bowel sounds in all four quadrants; however, there was a large firm, non-tender mass palpated in the right upper and lower quadrants. Also, bilateral mildly reducible inguinal hernias and a large umbilical hernia were detected. Patient's exam was otherwise normal.
The patient has recovered well without complications, except for mild ileus, and was discharged on postoperative day fourteen to follow up for possible adjuvant chemotherapy.
Although the patient underwent surgery without complications, there is no doubt that his mental illness prevented him from seeking medical care sooner. It is unusual that the abdominal mass grew as large as it did without signs of bowel obstruction or perforation.
Small and/or large bowel obstruction in patients with cancer is a common and difficult problem and has been described in 28–38 percent of patients with colorectal carcinoma[3, 4]. Cases of obstructions and perforations have been documented with masses well below 6 cm in diameter. This is an unusual case of a 13 × 12 × 16 cm colonic adenocarcinoma without any signs of obstruction or perforation.
Obstruction and/or perforation are important predictors of prognosis with respect to colorectal carcinomas. In adenocarcinoma of the colon, obstruction and perforation have been documented to have occurred at the site of the neoplasm and/or proximal. In one study alone, close to 2000 cases of colorectal adenocarcinoma with obstruction and perforation were examined and showed that both events carry a poor prognosis. In a study by Wang et al, of 256 patient outcomes examined, survival rates were significantly lower in obstructed patients. This study also found obstruction status as an independent prognostic factor for patients with right colon carcinoma.
Studies across the world consistently show poorer outcomes for patients with obstructive colorectal cancer as opposed to non-obstructed cancer. A study performed in Asia documented the perioperative mortality rate for colorectal cancer with obstruction to be 5% and the 5-year survival to be 33%. Zucchetti et al showed that radically resected obstructed patients had a disease-related death rate of 47.6% versus 16.3% for non-obstructed ones. Their study, performed in Europe, concluded that obstruction itself represented an independent unfavorable factor negatively affecting long term prognosis, even after radical resection. In another study done in South America, Torres-Zavala et al showed survival rate of patients with obstructive colorectal cancer to be 9.5% versus 35.1% for non-obstructive ones.
TNM Staging System for Colorectal Cancer
Primary Tumor (T)
Tis: Carcinoma in situ; intraepithelial (within glandular basement membrane) or invasion of lamina propria (intramucosal)
T1: Tumor invades submucosa
T2: Tumor invades muscularis propria
T3: Tumor invades through the muscularis propria into the subserosa, or into nonperiotonealized pericolic or perirectal tissues
T4: Tumor directly invades other organs or structures, and/or perforates visceral peritoneum
Regional Lymph Node (N)
NX: Regional nodes cannot be assessed
N0: No regional node metastases
N1: Metastasis in 1 to 3 regional lymph nodes
N2: Metastasis in 4 or more regional lymph nodes
Distant Metastasis (M)
MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
Stage 0: Tis, N0, M0
Stage I: T1-2, N0, M0
Stage IIA: T3, N0, M0
Stage IIB: T4, N0, M0
Stage IIIA: T1-2, N1, M0
Stage IIIB: T3-4, N1, M0
Stage IIIC: Any T, N2, M0
Stage IV: Any T, Any N, M1
In this case, the tumor had invaded the retroperitoneal tissue (T4), zero out of sixteen nodes were found positive (N0), and no distant metastasis was discovered (M0). It is highly unusual that this Stage IIB (T4, N0, M0) tumor was found without any signs of obstruction or perforation.
Nevertheless, one cannot dismiss the fact that the patient's mental status could have "blunted" his true physical presentation. In other words, with chronically depressed individuals, such as in this case, it is difficult to determine whether the loss of appetite and weight loss is secondary to their mental illness(es) or cancer. Even with a thorough history and physical, the clinician can be misguided, especially if the patient is not presenting other symptoms that would make him/her more suspicious of other underlying conditions.
The incidence of colorectal cancer makes it a very common disease process across the world. Perioperative mortality rates for colorectal cancer with obstruction have been documented anywhere from 5% to 47.6%, making obstruction an important predictive factor in long-term patient survival. Although a correlation between obstruction and patient outcome has been determined, a correlation between colorectal tumor size/staging and obstruction has yet to be investigated.
Written and verbal informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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