Case of metachronous bilateral isolated adrenal metastasis from colorectal adenocarcinoma and review of the literature

Rarely has a solitary, metachronous bilateral adrenal metastasis of colorectal cancer been reported. We depict a 41-year-old man who underwent sigmoid colon cancer radical surgery followed by adjuvant chemotherapy for a locally ulcerative sigmoid adenocarcinoma with metachronous bilateral adrenal metastasis revealed by a computed tomography scan. Histopathological examination showed adenocarcinoma, compatible with metastasis from the rectal cancer. The level of serum carcinoembryonic antigen had indicative significance for the presence of adrenal metastasis in the reported series. We performed a literature analysis related to this pathological characteristic and attach importance to consistent, vigilant radiological surveillance of the adrenal glands in the patients’ follow up for colorectal cancer with or without subsequent adrenal metastasis.

Comparison of non-schistosomal rectosigmoid cancer and schistosomal rectosigmoid cancer

AIM

To compare the clinicopathological features of patients with non-schistosomal rectosigmoid cancer and schistosomal rectosigmoid cancer.

METHODS

All the patients with rectosigmoid carcinoma who underwent laparoscopic radical surgical resection in the Shanghai Minimally Invasive Surgical Center at Ruijin Hospital affiliated to Shanghai Jiao-Tong University between October 2009 and October 2013 were included in this study. Twenty-six cases of colonic schistosomiasis diagnosed through colonoscopy and pathological examinations were collected. Symptoms, endoscopic findings and clinicopathological characteristics were evaluated retrospectively.

RESULTS

There were no significant differences between patients with and without schistosomiasis in gender, age, CEA, CA19-9, preoperative biopsy findings or postoperative pathology. Patients with rectosigmoid schistosomiasis had a significantly higher CA-125 level and a larger proportion of these patients were at an early tumor stage (P = 0.003). Various morphological characteristics of schistosomiasis combined with rectosigmoid cancer could be found by colonoscopic examination: 46% were fungating mass polyps, 23% were congestive and ulcerative polyps, 23% were cauliflower-like masses, 8% were annular masses. Only 27% of the patients were diagnosed with rectal carcinoma preoperatively after the biopsy. Computed tomography (CT) scans showed thickened intestinal walls combined with linear and tram-track calcifications in 26 patients.

CONCLUSION

Rectosigmoid carcinoma combined with schistosomiasis is associated with higher CA-125 values and early tumor stages. CA-125 and CT scans have a reasonable sensitivity for the accurate diagnosis.

A case of type 2 diabetes and metastatic liver cancer exhibiting hypercholesterolemia with abnormal lipoproteins

Although the appearance of abnormal lipoproteins in liver diseases is well known, the precise analyses of abnormal lipoproteins remain elusive. Here, we report a 71-year-old woman with type 2 diabetes whose serum cholesterol levels were elevated to 560 mg/dL over a 4-month period. High-performance liquid chromatography demonstrated the presence of lipoprotein-X and lipoprotein-Y and sigmoid colon cancer and multiple liver metastases were found by colonoscopy and computed tomography. Remission of the primary colon cancer and liver lesions was achieved by chemotherapy with oxaliplatin and fluorouracil and her serum cholesterol went back to basal levels associated with the disappearance of abnormal lipoproteins.

[Multiple liver metastases due to sigmoid colon cancer successfully treated by degradable starch microspheres (DSM)-TAE, radiofrequency ablation therapy, and Uzel/UFT]

A69-year-old man was diagnosed with sigmoid colon cancer and underwent resection of the sigmoid colon. He was later diagnosed with multiple liver metastases 11 months after resection of the sigmoid colon cancer. He was treated by intraarterial chemoembolization using degradable starch microspheres (DSM) and radiofrequency ablation therapy. As a systemic therapy, combined oral administration of tegafur/uracil (UFT) and Leucovorin(Uzel) was started (UFT 450 mg/day, Leucovorin 75 mg/day, 4 weeks of therapy followed by a 1-week treatment break). Two months after 4 courses, the liver metastases had markedly diminished and CEA was within the normal range. The metastases had almost disappeared and tumor markers decreased to within normal limits. This treatment was very safe and effective. Such a strategic multidisciplinary treatment can lead to a better prognosis for colorectal cancer with liver metastases.

[A case of advanced sigmoid colon cancer with peritoneal dissemination responding to FOLFOX4 therapy]

A 62-year-old woman complained of thin feces, lower blood and abdominal pain, and she was diagnosed as having bowel obstruction due to sigmoid colon cancer. Abdominal CT showed peritoneal dissemination and ascites on the surface of liver. The serum CEA levels were 663.7 ng/mL. We established a diagnosis of unresectable sigmoid colon cancer accompanied by severe peritoneal dissemination and therefore performed only transverse colostomy in April, 2006. Pathological examination of omental dissemination demonstrated moderately-differentiated adenocarcinoma. FOLFOX4 therapy was started on April, 2006. Primary lesion decrease and release from bowel obstruction after 4 cycles was judged as a partial response. The partial response continued, and the serum CEA decreased 18.5 ng/mL after completion of 16 cycles, but grade 3 neuropathy occurred. We started S-1 as second-line chemotherapy in May, 2007. There was primary lesion re-growth after 4 cycles, so we changed to S-1+CPT-11 therapy. The adverse events were grade 3 neuropathy and leucopenia throughout the course. Chemotherapy is now continued on an outpatient basis, 24 months after the medical treatment started. FOLFOX4 therapy is useful for patients with advanced colon cancer accompanied by peritoneal dissemination.

[A case of advanced sigmoid colon cancer performed resection of liver metastases after long-term control by S-1 and CPT-11 combination chemotherapy]

A 60-year-old man diagnosed as advanced sigmoid colon cancer was performed sigmoidectomy and D3 lymph node dissection. Intra-operative findings were SE, P0H1N4M (-), and Stage IV. One month after the operation, we started a combination chemotherapy using S-1 plus CPT-11 as one course for five weeks. S-1 (120 mg/body/day) was orally administered continuously for 3 weeks, and CPT-11 (80 mg/m2) was done intravenously on days 1 and 15. A Follow-up abdominal CT scan revealed a drastic reduction of liver metastasis and disappearance of para-aortic lymph node swelling (PR in). The combination chemotherapy was once finished after eight courses due to the patient's request. However, we started to administer the same regimen to him again six months later because of re-growth of liver metastasis. An additional six-course administration resulted in a reduction of liver metastasis by CT scan, and no other abnormal concentration besides two liver metastases by PET-CT examination was observed, and we performed a partial resection (two parts) of the liver and cholecystectomy 24 months after the first operation. The patient has been alive with disease free for five months since the second operation.

[A case of peritoneal disseminated sigmoid colon cancer with liver metastasis responding to S-1]

In October 2004, a 73-year-old man underwent loop ileostomy because of unresectable peritoneal disseminated sigmoid colon cancer with liver metastasis. The oral chemotherapy by S-1 was administered(80 mg/day for 4 weeks followed by a 2-week rest period). A half year later, the primary lesion was remarkably diminished on barium enema, and peritoneal dissemination and liver metastasis disappeared on CT. Because he was unwilling to have an ileostomy, we decided to resect the primary lesion and close the ileal stoma in May 2005. There was no obvious peritoneal dissemination, and operation was successful. He died without intestinal stoma one year after second operation. This therapy can be orally administered at home, and is considered to be useful from the viewpoint of QOL as well. S-1 is expected to be an effective agent for the treatment of colon cancer.

[A case of sigmoid colon cancer with multiple liver metastases responding to S-1]

A 74-year-old woman was referred to our hospital with complaints of constipation and abdominal distention caused by a sigmoid colon tumor. After examination, she was diagnosed as sigmoid colon cancer with multiple liver metastases. To prevent bowel obstruction, a sigmoid colon resection was performed. On postoperative days 15, S-1 was started, and she was discharged on postoperative day 26. Each course consisted of daily oral administration S-1 for 4 weeks followed by 2 drug-free weeks. However, because of grade 2 anorexia in the 1st course, the treatment plan was changed to administration for 2 weeks and withdrawal for 1 week. After 7 courses of treatment, computed tomography revealed that the liver metastases were remarkably reduced. Although she experienced an adverse event involving a cutaneous symptom of grade 2, the treatment was continued under ambulatory management. After eight courses, elevation of tumor marker and metastasis at the right femur were found, and she died of the cancer 12 months after the operation. S-1 is expected to be an effective agent for the treatment of advanced colorectal cancer.

[A successful treatment with down-staging chemotherapy for sigmoid colon cancer with unresectable multiple liver and lung metastases]

A 63-year-old woman was diagnosed as having a sigmoid colon cancer with synchronous unresectable multiple liver and lung metastases. After sigmoidectomy, she was treated with S-1 combined with CPT-11 as a down-staging chemotherapy. After 3 courses of chemotherapy, the liver and lung metastases reduced in size as partial response. In March 2005, extended right hepatectomy combined with MHV resection was performed. She was treated with 2 courses of chemotherapy after hepatectomy, and furthermore she underwent left lung upper lobectomy. She has been alive without any signs of recurrence for 33 months from the initial surgery. Recently, a progression of the systemic chemotherapy for colorectal cancer has been a promising modality to improve a poor prognosis for unresectable multiple liver or extrahepatic metastases from advanced colorectal cancer.

[A long-term survival case of advanced sigmoid colon cancer with massive metastases to the para-aortic lymph nodes]

We report a long-term survival case of advanced sigmoid colon cancer with massive metastases to the para-aortic lymph nodes. The patient was a 63-year-old male. He underwent sigmoidectomy with D3 + para-aortic lymphadenectomy for advanced sigmoid colon cancer. Histological examination showed a moderately differentiated adenocarcinoma, ss, ly2, v2, n4 (total 30/64, para-aortic lymph nodes 18/39). From 6 months to 4 years after the operation, tegafur/uracil (UFT) was performed as chemotherapy. After 8-year disease-free interval, CT showed solitary mediastinal lymph node metastases. He underwent thoracoscopic mediastinal lymphadenectomy. Histological examination revealed metastases from colon cancer.

[FOLFOX 4 in a patient with metastatic colorectal cancer on hemodialysis due to chronic renal failure]

A 68-year-old woman was on dialysis for the treatment of chronic renal failure. FOLFOX 4 therapy was performed following CPT-11+UFT+Leucovorin for liver metastasis after resection of cancer of the sigmoid colon. The dose of oxaliplatin was 40 mg/m2, while 5-FU was given as a bolus of 300 mg/m2, and a continuous intravenous infusion of 500 mg/m2. Hemodialysis was performed 1 hour after administration of oxaliplatin on day 1 and was repeated two days later after the completion of drug administration. Vomiting (grade 2),anorexia and leukopenia (both grade 3) were observed after the first treatment. A total of 4 courses were administered thereafter by reducing the dose of oxaliplatin to 32 mg/m2, the intravenous bolus of 5-FU to 240 mg/m2, and continuous infusion of 5-FU to 400 mg/m2. Measurement of drug concentrations showed that free platinum was immediately eliminated by dialysis. It was considered possible to safely perform FOLFOX 4 therapy in patients with chronic renal failure by reducing the doses and by providing dialysis. It is desirable to measure drug concentrations in these patients. Also,more cases should be monitored to investigate the safe dose,the blood drug concentration profile, and the accumulation of chemotherapy agents.

Humoral hypercalcemia complicating adenocarcinoma of the sigmoid colon: report of a case

Humoral hypercalcemia can arise from a variety of malignancies, but its association with primary colorectal carcinoma is rare, with only 20 such cases documented in the English-language literature to date. We report an additional case to clarify the clinicopathologic features of colorectal carcinoma with humoral hypercalcemia. A 54-year-old woman was admitted with symptomatic hypercalcemia of 14.2 mg/dl and multiple hepatic metastases, 2 years after resection of sigmoid colon cancer. The hypercalcemia was caused by the circulating parathyroid hormone-related peptide (PTHrP) produced by poorly differentiated adenocarcinoma in the liver. The PTHrP level on admission was 13.5 pmol/l. Despite systemic chemotherapy, the patient died of disease progression 3 weeks after the humoral hypercalcemia was diagnosed. A review of the 21 reported cases, including ours, suggests that colorectal carcinoma associated with humoral hypercalcemia is characterized by a poorly differentiated tumor with or without squamous or neuroendocrine features, distant metastases, and a dismal prognosis.

Systemic cytokine response after laparoscopic-assisted resection of rectosigmoid carcinoma: A prospective randomized trial

OBJECTIVE

To compare the systemic cytokine response in patients after laparoscopic-assisted resection with those after open resection of rectosigmoid carcinoma.

SUMMARY BACKGROUND DATA

Laparoscopic resection of colorectal carcinoma is technically feasible, but objective evidence of its benefit is scarce. Systemic cytokines are accepted as markers of postoperative tissue trauma and mediators of the host immune response.

METHODS

Thirty-four patients with rectosigmoid carcinoma, without evidence of metastatic disease and suitable for laparoscopic resection, were randomized to undergo either laparoscopic (n = 17) or conventional open (n = 17) resection of the tumor. Clinical parameters were recorded. Sera were collected before surgery and at appropriate time points afterward and assayed for interleukin-1beta, tumor necrosis factor-alpha, interleukin-6, and C-reactive protein. The primary end points were the cytokine and C-reactive protein levels. Data were analyzed by intention to treat.

RESULTS

The demographic data of the two groups were comparable. The clinical outcome of both groups was satisfactory, with no surgical deaths and a reasonable complication rate. Both interleukin-1beta and interleukin-6 levels peaked 2 hours after surgery, with the responses in the laparoscopic group significantly less than those in the open group. C-reactive protein levels peaked at 48 hours, and the difference was also statistically significant. Levels of tumor necrosis factor-alpha were not elevated after surgery, and there was no difference between the groups.

CONCLUSIONS

Tissue trauma, as reflected by systemic cytokine response, was less after laparoscopic resection than after open resection of rectosigmoid carcinoma. The difference in the systemic cytokine response may have implications on the long-term survival.

Soluble CD44: quantification and molecular repartition in plasma of patients with colorectal cancer

Based on the important role of CD44 in tumour progression and metastasis, we evaluated, in a prospective study, plasma-soluble CD44 (sCD44) as a serum marker in colorectal cancer. Blood plasma specimens from 89 patients with colorectal neoplasm, 22 patients with a gastrointestinal disease and 23 healthy donors were analysed for quantitation (ELISA assay) and purification of sCD44. The concentration of sCD44, indicating the concentration of all isoforms, was significantly higher in patients with colorectal cancer and intestinal disease than in normal individuals, but no significant differences were found between the two groups. We found no association between plasma levels and staging of the colorectal cancer patients according to Astler and Coller. A two-step batch purification combining ion exchange and immunoaffinity chromatography, followed by Western blot analysis, revealed a complex pattern with a major band corresponding to the standard form of CD44 and minor bands that may correspond to larger variant forms. No particular sCD44 isoform was clearly associated with anatomopathological or biological information.

Chromosome instability in lymphocytes from two patients affected by three sequential primary cancers: the role of fragile sites

The chromosomal aberration rate and the expression of fragile sites induced by aphidicolin were evaluated in metaphase chromosomes obtained from peripheral blood lymphocytes of two untreated patients with multiple primary cancers. Spontaneous aberrations of chromosome number and structure and chromosome fragility were compared with controls with the use of the same methods. Chromosomal aberration rates and expression frequencies of fragile sites were significantly higher in the patients than in normal control subjects. In the patients, all but one structural chromosome aberration involved at least one fragile site. Our results suggest that fragile sites may be unstable regions of the human genome, which might play an important role in the genetic instability associated with cancer predisposition.

Successful resection of sigmoid colon cancer in a patient with factor XI deficiency

A 42-year-old-women with sigmoid colon adenocarcinoma was found to have isolated prolonged activated partial thromboplastin time (aPTT 102.5 s, normal range 24-36 s) preoperatively. Her medical history included an episode of prolonged postdelivery uterine bleeding 16 years previously. A mixed aPTT test showed immediate correction of the prolonged aPTT, indicating a coagulation factor deficiency in the intrinsic pathway. Factor assays showed factor XI was below 1% of average normal value whereas factor VIII, IX and XII activities were normal. Family screening revealed one sister among the three siblings also had isolated prolonged aPTT. The patient was transfused with four units (5mL/kg) of fresh frozen plasma the day before surgery, then with two units during surgery. The operation was uneventful with no bleeding problems. The patient recovered smoothly and is currently undergoing adjuvant chemotherapy. This is the first formal report of a patient with factor XI deficiency undergoing major surgery in Taiwan. Careful monitoring of aPTT, with fresh frozen plasma transfusion, when needed, may safely overcome bleeding problems during surgery.

The risk factor profile of recto-sigmoid adenomas: a prospective screening study of 665 patients in a clinical rehabilitation centre

During a prospective screening study for recto-sigmoid adenomatous polyps, the influence of the following risk factors was evaluated: age; gender; body mass index; heredity for colorectal malignancy; diabetes; hypertension; constipation; previous gastric surgery; previous gastric acid inhibition; alcohol and cigarette consumption; serum cholesterol; serum triglycerides; and serum gastrin. Screening fibre-sigmoidoscopy of 665 patients (aged between 50 and 60 years) at a clinical rehabilitation centre for gastrointestinal and metabolic diseases showed that 146 had one or several adenomas. The study population was overweight by a mean of about 15%. Comparison of those with and those without adenoma using univariate analysis, showed that the group with adenomas had higher serum triglyceride values, drank more alcohol on a regular or excessive basis, were more frequent smokers, and had a tendency to raised fasting serum glucose. In a multivariate analysis, age, high serum triglycerides and high alcohol consumption were risk factors for recto-sigmoid adenomas. The risk factor profile identified in this study may help in the selection of individuals for screening sigmoidoscopy from a similar background population. It also identifies target conditions for primary prevention of colorectal neoplasia.

Feasibility of photodynamic therapy using endogenous photosensitization for colon cancer

A novel approach to photodynamic therapy (PDT) involves endogenous photosensitization by the oral administration of delta-aminolevulinic acid (ALA), a naturally occurring substance that is the precursor of protoporphyrin IX (PpIX). A 60-year-old man with adenocarcinoma of the sigmoid colon received ALA, 60 mg/kg by mouth. Six hours later, when the plasma level of PpIX had peaked, the tumor was exposed locally to red light at 633 nm to activate PpIX. Endoscopy and biopsy findings subsequent to this treatment showed unequivocal visible changes and necrosis. Six months later, the patient again underwent successful treatment without adverse effects. This report suggests a role for PDT using endogenous photosensitization in certain circumstances involving adenocarcinoma of the large intestine.

The absence of a B allele in acquired B blood group phenotype confirmed by a DNA based genotyping method

A case of an 87 year old woman with carcinomatous sigmoid colon, found to be of group A1 with acquired B status, is reported. The acquired B phenotype was confirmed by the absence of a B allele in the patient using denaturing gradient gel electrophoresis of a DNA fragment amplified from the ABO locus by the polymerase chain reaction.

Metastatic vipoma arising from colonic primary tumour

We describe a case of a tumour of the sigmoid colon with hepatic metastases in a patient with previously documented ulcerative colitis. A diagnosis of metastatic vipoma was made on the basis of high plasma levels of vasoactive intestinal polypeptide (VIP). Profuse diarrhoea and profound metabolic upset were corrected by the use of a somatostatin analogue SMS 201-995, whilst conventional cytotoxic therapy produced a significant tumour response with return of the plasma VIP level to normal.

Preoperative serum markers in carcinoma of the rectum and rectosigmoid. I. Prediction of tumour stage

Preoperative serum concentrations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and a monoclonal-antibody-defined carcinoma-associated carbohydrate antigen, CA-50, were measured in 272 consecutive patients with histopathologically proven rectal carcinoma. The levels of all three tumour markers correlated directly to the stage of the disease. The serum TPA reflected both the local tumour burden and any metastatic spread, as shown by analysing mean levels of S-TPA and by the use of a Walker and Duncan regression model. S-CA-50 separated patients with and without distant metastases, but not with regard to the local tumour burden. Although the level of S-CEA correlated to the tumour stage, it did not discriminate patients with respect to locally advanced growth or generalized disease. In a multivariate analysis, the serum level of TPA was found to be the most informative preoperatively. Both S-CA-50 and S-CEA gave information additional to that provided by S-TPA in the prediction of the tumour stage (Dukes' stage A-D), and S-CA-50 was also useful in the prediction of metastatic disease.

Preoperative serum markers in carcinoma of the rectum and rectosigmoid. II. Prediction of prognosis

The prognostic value of a single preoperative determination of the serum (S) concentration of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and the carcinoma-associated carbohydrate antigen CA-50, either alone or in combination was evaluated in 327 consecutive patients with carcinoma of the rectum. A strong correlation was found between the serum level of each of these tumour markers separately, and prognosis, both in terms of crude survival in all patients and in disease-free survival in 'potentially cured' patients. The prognostic information provided by S-TPA and S-CA-50 was stronger, however, than that given by S-CEA. In a multivariate approach, S-TPA was found to be most informative. With use of the Cox regression model, the critical serum values that best separated patients in regard to mortality were CEA 18 micrograms/l, TPA 120 U/l and S-CA-50 40 U/ml. The critical values that best discriminated disease-free survival in 'potentially cured' patients were CEA 12 micrograms/l, TPA 110 U/l and S-CA-50 28 U/ml. The clinical usefulness of these and other cut-off levels is discussed.

Acquired factor IX inhibitor in a patient with adenocarcinoma of the colon

The association of an acquired inhibitor to factor IX and adenocarcinoma of the sigmoid colon is reported here for the first time. Unlike the lupus anticoagulant, the inhibitor identified did not exhibit marked prolongation of the clotting time using a highly diluted thromboplastin nor was the kinetic behavior of the inhibitor-factor IX interaction time-dependent. Administration of prednisone was associated with the return of the activated partial thromboplastin time to normal values, at which time the tumor was excised and corticosteroids discontinued with no evidence of subsequent factor IX inhibitor activity.

[Serum alpha 1-fetoprotein and extrahepatic digestive cancers. Apropos of 4 further cases]

The authors report four new cases of primary digestive carcinoma other than hepatoma with alpha 1 feto-protein in the serum (greater than 200 ng/ml). Two were carcinoma of the colon without liver metastases. The remaining two were also colonic carcinoma but with liver metastases. In the first cases, alpha 1 feto-protein disappear after surgical procedure. In spite of the rareness of primary digestive carcinoma with presence of alpha 1 feto-protein noted until now, these cases require reconsideration of the idea that AFP is specific for hepatoma.

Preliminary longitudinal studies of serum polyamines in patients with colorectal carcinoma

Polyamines, whose biosynthesis is a prerequisite for cell proliferation, are potential indicators of malignant growth. In view of this, serum polyamine levels were examined in longitudinal studies of patients with either colorectal carcinoma or Gardner's syndrome (inherited colonic polyposis possessing a potential for malignant degeneration). Of 10 patients examined longer than one year, serum polyamine levels reflected the disease status. This study indicates that biochemical surveillance of patients by polyamine analysis may be feasible and possibly applicable to other types of tumors.

[Cis-polyenecarboxylic acids and other fat-metabolism parameters in carcinoma of the digestive tract]

In 24 patients with a neoplasm of the gastro-intestinal tract cis-poly-unsaturated fatty acids were determined in the serum together with cholesterol, free and total glycerin as well as with neutral fats. In the cis-polyene acids a statistically ascertained diminution occurs, all the other parameters remain practically unchanged. To what extent very low values of poly-unsaturated fatty acids are to be connected must still be tested. It cannot be judged about a correlation of cancer and values of neutral fats, since the breadth of the normal area of this parameter of fatty metabolism is very large and the number of test persons is relatively small. The content of cholesterol of patients with cancer is prettily constant and deviated only little from the normal.

Anaemia in the elderly: caveat caecum

The experience of a professorial unit over a four-year period of carcinoma of the colon and rectum is described. The high incidence of anaemia in lesions proximal to the splenic flexure is shown. The distressing misdiagnosis of the cause of this anaemia is pointed out, and the consequent misuse of haematinics in the form of blood transfusion, iron and vitamin B12 is shown.