A Case of Progressive Abdominal Pain Leads to a Surprise Finding

A 29-year-old lady presents to an emergency division in Riyadh, Saudi Arabia, due to progressive abdominal discomfort. In addition to feeling bloated and vomiting periodically, she has not had a bowel movement in 14 days. She says she has no appetite and has lost weight, even though she has not been maintaining a record of the specifics. Her referring doctor has supplied the patient with a computerized tomography (CT) scan of her abdomen and pelvis and a report noting a mass obstructing her left colon. Her healthcare history incorporates breast cancer on her mother's side of the household. Clinical Examination The patient appears frequently unwell. Clinicians note abdominal distension, tympanic by percussion, with the rectum empty of stool. The patient has tachycardia her heart price is up to 120 bpm. Findings of lab tests are unremarkable except for a higher carcinoembryonic antigen level (218 ng/mL). Abdominal x-rays in each the erect and supine positions reveal a number of air-fluid levels and a dilated bowel, with no air beneath the diaphragm. Clinicians place the patient on NPO (absolutely nothing by mouth) status, with intravenous hydration and nasogastric tube decompression. Review of the CT abdomen and pelvic photos with the radiologist identifies a circumferential descending colon mass with a number of regional lymph nodes and proximal dilatation. CT scan of the abdomen displaying: (A) Coronal view of circumferential wall thickening of the descending colon (significant arrows) linked with modest regional lymph nodes (extended arrows) and (B) Axial view of circumferential wall thickening of the descending colon (significant arrows) with mild luminal narrowing. After resuscitation, the gastroenterology group is consulted, and agrees on colonoscopic stenting as emergency therapy. Colonoscopy reveals a fungating descending colon mass obstructing the lumen a number of biopsies are taken. Under guide wire, a 9 cm uncovered stent is inserted, and stool starts to come by way of it. After the process, clinicians acquire an erect abdominal x-ray, which shows no indicators of perforation. The patient returns to regular bowel movements and an oral diet plan, which is nicely tolerated. Treatment Decisions The pathology report from the biopsies indicates moderately differentiated adenocarcinoma with infiltration of the muscularis mucosa. To ascertain staging, clinicians execute CT chest and abdominal magnetic resonance imaging, which show no proof of metastasis. The patient is scheduled for a laparoscopic left hemicolectomy. Surgery reveals a descending mass surrounded by inflammatory tissue. The incidental obtaining of an appendicular mass at the base is identified with dilated appendix and indicators of inflammation. The surgical group decides to proceed with laparoscopic-assisted subtotal colectomy with ligation of the left colic, middle colic, ideal colic, and ileocolic arteries and key ileocolic anastomosis. The resected significant bowel is 75 cm in length with a circumferential left colon mass. The metal stent effectively identifies and stabilizes the mass. The appendix is 6×1.five cm, with a heterogeneous yellow-tan firm mass. The patient recovers nicely following the surgery, with no complications. She is discharged on the sixth postoperative day in steady situation. Pathology The surgical pathology report shows a moderately differentiated left colon mass measuring 11. cm in greatest dimension, with invasion by way of the muscularis propria into the pericolic tissue. Lymphovascular invasion is noted 28 lymph nodes are identified, all of which are damaging for metastases. Left colon adenocarcinoma is labeled as pT3, N0, Mx. The mass on the appendix is a nicely-differentiated neuroendocrine tumor, which is good for chromogranin and synaptophysin. There is proof of invasion to the serosa and mesoappendix. Lymphovascular invasion is also noted, and two of the 28 lymph nodes test good for neuroendocrine tumor. Appendicular carcinoid is labeled as pT3, N1, Mx. Clinicians talk about the case at a multidisciplinary tumor board meeting and in consideration of the patient's higher-danger status primarily based on the octreotide scan, determine to proceed with adjuvant chemotherapy. The scan is performed and findings are damaging. Based on the postoperative evaluation of the CT abdomen scan, the radiologist labels the appendix as a borderline appendix with no clear appendicular mass. One year later, the patient reports that she has completed the adjuvant chemotherapy cycles with no notable complications, and is consuming commonly with no difficulties, and is moving her bowels twice everyday. Findings of stick to-up CT scans and colonoscopy are unremarkable. Discussion Clinicians presenting this uncommon case of a patient with synchronous colorectal cancer and carcinoid tumors note that there is an ongoing debate about treating with a number of resections or an substantial resection. As nicely, clinicians face the challenge of obtaining an optimal healthcare or chemotherapy method to handle each malignancies. Synchronous key tumors refers to the look of two or much more distinct histological tumors in a single patient at the identical time or inside a period of six months. These cancers differ from metachronous tumors, and are diagnosed following the specified period of six months. Multiple key tumors have been reported for about 100 years malignancies with a number of growths represented four.7% of all reported cancer instances in 1921, and the prevalence price has elevated in current years to a reported price of 17% in some research. Clinicians note that sophisticated diagnostic methodology resulting in longer patient survival and an boost in the quantity of cancer survivors could account for this phenomenon. In the U.S., colorectal cancer is the third most prevalent cancer in males and females, as nicely as the third major lead to of cancer death. In Saudi Arabia, colorectal cancer is the most prevalent malignancy amongst males and the third most prevalent in females. On the other hand, synchronous colorectal cancer and carcinoid tumors are each fairly uncommon, with incidence prices of only two.six% and .66%, respectively, according to the National Cancer Institute's Surveillance, Epidemiology, and End Results database from 1973 to 2004, which also shows that whilst the incidence of all other malignancies has remained pretty steady, carcinoid tumors have been steadily escalating. Carcinoid tumors, or nicely-differentiated neuroendocrine tumors, are malignant strong cells derived from neuroendocrine secretory cells, and are discovered most typically in the bronchial or gastrointestinal systems, with the gastrointestinal tract accounting for about two-thirds of instances. Of these, the most prevalent gastrointestinal web pages are the modest bowel (45%), rectum (20%), appendix (17%), and stomach (9%). Carcinoid tumors can be classified into functioning and non-functioning varieties. Non-functioning tumors have a tendency to present as an incidental mass with or devoid of compression symptoms. Functioning tumors are linked with systemic symptoms as a outcome of the tumor cells' secretion of vasoactive substances, such as serotonin. Symptoms of carcinoid syndrome -- flushing, diarrhea, bronchoconstriction, and palpitation -- have a tendency to create following distant metastatic cells secrete these substances into the systemic circulation. The resulting excessive levels of serotonin can also lead to myocardial and valvular damage. As noted in a 2010 Canadian consensus statement, management of nicely-differentiated neuroendocrine tumors frequently requires surgical removal of all tumor cells. In instances exactly where curative surgery is not achievable, symptomatic and biochemical manage could be achievable by way of debulking surgery, radiofrequency ablation, hepatic artery embolization, somatostatin analogues, or chemotherapy. Efforts to address two distinct varieties of malignancies simultaneously involve identifying the healthcare or chemotherapeutic method that will provide the greatest therapeutic impact for each malignancies with minimal adverse effects and toxicity. The case authors note that there has been only a single report in the literature of synchronous appendicular carcinoid tumor with colon adenocarcinoma -- also in a young female with an obstructive left colon mass and an incidental obtaining of appendicular mass. That patient was also managed with total colectomy. A 2017 paper on the debate among a number of regional resections and substantial resection in synchronous colorectal cancer recommended that substantial resection is frequently applied and preferred by surgeons in the case of left and ideal colon lesions. However, there has been ongoing controversy about the therapy of ideal colon and rectum synchronous lesions, with superiority of two regional resections concerning functional bowel movements. The case authors conclude that synchronous colorectal cancer and carcinoid tumors are uncommon malignancies, and the challenge is to discover an optimal healthcare or chemotherapy method to handle each. Disclosures The case report authors note no conflicts of interest.

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