Distant manifestations of colonic carcinoma

Poorly differentiated colon carcinoma with neuroendocrine features presenting with hypercalcemia and cutaneous metastases: case report and review of the literature

Humoral hypercalcemia is rarely associated with colon carcinoma; cutaneous metastases from colon carcinoma are also infrequent. To the authors' knowledge, no cases of colon carcinoma presenting with both hypercalcemia and cutaneous metastases have been reported to date. A case of advanced poorly differentiated colon carcinoma with neuroendocrine features with both humoral hypercalcemia of malignancy (HHM) and cutaneous metastases is presented. A poorly differentiated colon carcinoma with neuroendocrine features occurred in a 42-year-old patient with metastases to the liver, both femurs, left orbit, and scalp. The hypercalcemia was caused by the expression of a parathyroid hormone related peptide by both the primary and cutaneous metastatic tumors. Bisphosphonate treatment helped normalize serum calcium in a few days, but hypercalcemia recurred approximately 3 weeks later. Chemotherapy only mildly reduced the size of the cutaneous metastases. The patient died 8 months after initial diagnosis. To the authors' knowledge, the case presented in the current study is the first to be reported with both HHM and cutaneous metastases. Hypercalcemia and cutaneous metastases are separately associated with a poor prognosis and indicate advanced and widely metastatic disease. Although still unclear, the mechanism by which colon cancer causes cutaneous metastases and hypercalcemia, in light of current theories presented in the literature, is discussed.

The Yale-Affiliated Gastroenterology Program. A personal note

The Yale-Affiliated Gastroenterology Program provides an effective combination of tutorial and group dynamics and may be the model for need-based training of subspecialists in communities. If the present university centers work in partnership with quality community programs, the consequent university program may offer more pertinent education and proceed in a more appropriate direction for the field of gastroenterology than that of the currently accepted agenda.

Adenosquamous carcinoma of the colon presenting with hypercalcemia

A rare adenosquamous carcinoma of the colon occurred in a 41-year-old patient. Its presentation with hypercalcemia, in the absence of osseous metastases, has not been described previously. The hypercalcemia in this case was due to the elaboration of a parathyroid hormone-like substance by the tumor. The general characteristics of primary adenosquamous and squamous cell carcinomas of the colon are presented. These tumors present with advanced disease, in younger patients, and follow a highly aggressive course, as compared with adenocarcinomas of the colon. The cause of the malignancies, in the light of current theories regarding their genesis, is discussed.

General metabolic abnormalities in cancer patients: anorexia and cachexia

Cancer cachexia is a chronic wasting illness directly associated with the presence of uncontrolled malignancy. The authors discuss the various causes of inadequate nutrient intake, including the known data on anorexia, and outline the potential role of humoral factors as mediators of cachexia.

Diagnostic delay in symptomatic colorectal cancer

Previous research on colorectal cancer patients has suggested that considerable delay can occur once the patient has sought medical care. However, little information has been available on the possible components of this delay. In this study, detailed information on diagnostic delays was collected from 294 symptomatic patients. Of these patients, 46% reported experiencing at least one delay. Three types of diagnostic delay were identified and were associated with different lengths of delay. Of all the delays, 31% were due to difficulties in scheduling initial or subsequent office visits or laboratory tests; these were associated with an average delay of 3 weeks. Physician-related delays (e.g., misdiagnosis or observation of symptoms without specific action) comprised 46% of all diagnostic delays and resulted in an average delay of 18 weeks. The remainder of the delays were patient-related and resulted in an average delay of 12 weeks. There was no association between any of these three delay types, suggesting that attempts to reduce diagnostic delay should encompass all three types in order to be maximally effective.

Fungal peritonitis and malignancy: report of two patients and review of the literature

Two patients developed isolated Candida albicans peritonitis in association with intraabdominal malignancy. Although additional factors predisposing to the development of fungal peritonitis were present, we postulate that tumor-related local factors permitted fungi to cross the gut wall and to enter the peritoneum, where the host immune status determined whether the infection spread. These two cases are the sixth and seventh reported cancer patients who developed fungal peritonitis, but the first two who had the fungal infection localized to the peritoneum; and this is the first report known to us specifically associating intraabdominal malignancy and fungal peritonitis. Patients who develop fungal peritonitis may have a primary or metastatic intraabdominal malignancy, and fungi should be considered as a cause of peritonitis in cancer patients.