Case 6, Session 2 and 3...


Investigations: Reduce PCV, MCV, MCH, MCHC and Hb in CBE. It suggests that the pt has moderate anaemia with moderate microcytosis, anisocytosis, poikilocytosis, and slight hypochromia. Increase platelets suggest bleeding.

Normal electrolytes, glucose, urine dipstick analysis and LFT. Normal ECG and CXR. However, there is positive result in faecal occult blood test, suggesting there is bleeding in the GIT (the speficity of the test is poor but it has good sensitivity).

She was referred to a surgeon.

Rigid sigmoidscopy: No abnormalities was seen to 15cm

Colonoscopy: Good bowel preparation. Pt tolerated the procedure well w/o complications. A pathology was encountered in hepatic flexure and limited the examination. An ulcerative tumour was present at the hepatic flexure. Biopsies was taken. The rest of visualization bowel was normal.

Carcinoembryonic antigen (CEA): undetectable

CT scan of abdomen: Liver=normal size and appearance. There's thickening in the mid-ascending colon suggestive of bowel wall pathology, and this correlates with the known R colonic cancer. No other abnormalities seen.

Biopsy: moderately differentiated adenocarcinoma.

She was referred for elective surgery. Was transfused with 3 units of packed blood cells over 18hours,w/o incident. Post-transfusion Hb level was 124 g/L, with hypochromic, microcytic picture still persisted.

Operation: Findings- a bulky tumour found in mid-ascending colon and the mesenteric lymph nodes slightly enlarged but nor hard. Liver appeared not involved by malignancy, and so thus the intraperitoneal.

Procedure- R colon to the middle colic vessels was resected and ileo-colic anastomosis performed.

Resected specimen sent for histology for formalin.

Pathological Diagnosis: R hemicolectomy; moderately differentiated colonic adenocarcinoma extending via main muscle coat with lymphatic invasion & regional lymph nodes involvement in 2 of the 12 retrieved nodes. Adjacent mildly dysplastic tubullovillous adenoma w/in resected specimen. Margins free of malignancy.

Microscopic report from biopsy: Ulcerating adenocarcinoma involve the muscularis propria with focal extension into subserosa. Twelve regional nodes were identifies and 2 are involved by metastatic tumour.

Stage: ACPS or Duke stage C

Post-operatively, her condition was satisfactory w/o need of further blood transfusion. Pain controlled by epidural anaesthasia. Hydration initially maintained with IV fluids. Urine output was satisfactory.

First 3 days after surgery, she had signs of reduced air entry at L lung base, but was cleared after physiotherapy. Mobilizing by the end of day 3, with assistance.

Day4: Bowel sounds present and began oral intake of fluids, progressed to a light diet by day 6, and normal diet thereafter. Wound healing well. Planned to discharge her in day 8 or 9.

Oncologist explained and discussed the importance of adjuvant chemotherapy. There was also appointment made to follow-up her conditions. She was told that she needed a number of investigations as part of her regular follow-up "surveillance", both by her GP and surgeon.

Take home messages:
1) According to Current Medical Diagnosis and Treatment 2005, adenocarcinoma in colorectal cancer "grow slowly and may be present for several years before symptoms appear". Not meaning that negative findings will rule out possible causes. 1+1 doesn't necessary be 2.

2) The symptoms may differ according to the site of the lesion. More signs eg. colicky pain, diarrhoea and constipation due to cancer will occur if the lesion is on the L side of the colon. R colon sometimes may take even years for the patient to realize that he/she has the neoplasm.

3) If the patient doesn't have metastases lymph nodes, would you consider for chemotherapy. Less likely. Because the chances of the stage I and II (A or B) 5 year survival is 90-100% and 60-75% respectively. However, for stage III (C), the 5 year survival can be risen from 30-50% to 40-65% with adjuvent chemotherapy, depends on the number of metastases nodes affected. For stage IV (D) ie. has distal metastases, the CMDT suggested for more palliative treatment for the patient, and the chemotherapy therapy doesn't show significant increase in the survival rate.

CANCER= sometimes can make people come forward closer to ALLAH.. but sometimes can make people go as far as they can from ALLAH.. Na'uzubillah..

Insya ALLAH. Whatever it is. Whether cancer or others. One thing for sure. We will die. There is no eternity life other that ALLAH. Thus. Always remember about death. Because it is very close to you. And also to my self.

Prophet Muhammad has said "the smartest people are people who remember about death"..