Case 124: A 45 y/o man with Occult Blood in his Stool

History This 45 year-old male veteran was admitted to the Omaha Veterans Administration Hospital for workup of a positive occult blood test. This patient tested his own stool with an occult blood test supplied by Methodist Hospital and WOWT (television station). The hospital informed him that the test was positive and he should seek medical attention. Past medical history revealed mild chronic bronchitis and mild hypertension currently being treated with propranolol. The patient received a recent cholecystectomy. Family history; a brother (age 47) had colon cancer, their father died at age 60 of colon cancer, and one of the father’s sisters had endometrial carcinoma.

P. E. a well-developed, well-nourished male in no acute distress. BP 140/90, P.= 80/min, Resp 16/min. HEENT: within normal limits, neck was supple and no bruit heard Chest: occasional rhonchi noted, otherwise auscultation and percussion unremarkable Heart: regular rhythm at 80/min - no murmurs Abdominal exam: no masses or tenderness on palpation Bowel sounds: normal, active Rectal exam: an enlarged but non-tender nodular prostate, but no rectal lesions felt Stool occult blood test: positive

Write a problem list and differential Write a problem list and differential. What tests and/or procedures would your order at this time?

Labs: CBC: Hgb: - 11.3 gm/dL MCV: - 72 FL WBC: - 8.0 x 103/ L Diff.: - unremarkable Platelets: 240,000 mm3 Urinalysis: - unremarkable Chemistry: Electrolytes Na: 140 mmol/L, K: 4 mmol/L, Cl: 100mmol/L, CO2 (HCO2): 22 mmol/L BUN - 16 mg/dL Creatinine - 1 mg/dL Glucose - 90 mg/dL

Discuss the implications of finding occult blood in the stool Discuss the implications of finding occult blood in the stool. (Discuss in terms of age groups, gender, and possible causes.) Explain the hematology findings. Outline the workup of a positive stool occult blood test. (Look this up!) What would you do next?

Additional Lab Results Serum Fe 28 micrograms/dL

The patient had a flexible colonoscopic examination of the entire colon and a large sessile villous lesion was noted in the ascending colon. Biopsies showed a “villous adenoma; however, the presence of invasive carcinoma could not be ruled out.” The patient subsequently underwent a segmental resection of the right colon which revealed a large villous adenoma with a small ulcer in the center. Visual examination of the abdominal cavity showed no evidence of neoplastic disease.

Role of colonoscopy and biopsy

Surgical resection specimen- segment of large bowel- large villous adenoma( looks like a ‘shaggy rug’). Ulcer in center may be from biopsy

Cut section of villous adenoma Cut section of villous adenoma. Looks like a wart-- grossly it does not invade into the muscularis

Normal colon: Note the normal mucosa with muscularis mucosa.

Another look at normal colon. Note distribution of goblet cells Another look at normal colon. Note distribution of goblet cells. Note that the nuclei are generally at the base of the cells.

Comparison of normal mucosa and adenomatous epithelium Comparison of normal mucosa and adenomatous epithelium. Note loss of goblet cells and general darkness at base of the cells - this represents enlargement of nuclei and increased DNA in the neoplastic cells. These are not malignant yet--there is still good basement membrane around the glands and there is no evidence of invasion through the muscularis mucosa Normal adenomatous

The majority of the lesion, a villous adenoma as shown in this photomicrograph

Scanning power photomicrograph Scanning power photomicrograph. Note the neoplastic glands in the submucosa, undermining the villous adenoma.

A area of invasive carcinoma deep in the muscular wall: note irregular gland formation

High power photomicrograph of the neoplasm.

What is a polyp. A villous adenoma. A flat adenoma What is a polyp? A villous adenoma? A flat adenoma? And what are their relationship to colon carcinoma? Describe the gross morphologic patterns of carcinoma of the colon and symptoms and signs associated with each.

Another villous adenoma

Classic ‘applecore’ lesion of the left colon Gross specimen showing a common manifestation of adenocarcinoma of the colon. This is a constricting "napkin ring" lesion. This is more common in the descending and sigmoid colon. This lesion may or may not bleed.

Fungating lesion (classic for right colon) Example of a small ulcerated adenocarcinoma. This is the type of lesion that typically presents with positive fecal occult blood test.

Grade and stage is this man's tumor in the modified Dukes (Astler-Coller) and TNM system? How does the grade relate to the stages?

Diagrammatic view demonstrating the modified Dukes staging system

What is the five-year survival rate What is the five-year survival rate? Or how would you explain his survival to him and his family (be specific – patients don’t want generalities – look this up on the web – your patient has!)

http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_colon_and_rectum_cancer_staged.asp

Comparison of AJCC, Dukes, and Astler-Coller Stages AJCC/TNM Dukes Astler-Coller 5 year survival I A A, B1 93% IIA B B2 85% IIB B3 72% IIIA C C1 83% IIIB C2, C3 64% IIIC C1, C2, C3 44% IV D 8%

Chart with the prognosis according to modified Dukes(Astler/Coller) stage in 1954 (compare to today)

What risk factors are associated with colon carcinoma? Outline the work up of a positive stool occult blood test. Describe the histologic and cytologic criteria of malignancy? What is anaplasia? What is the role of carcinoembryonic antigen (CEA) test in the diagnosis and management of colon carcinoma. What is the significance of the positive family history? What is the molecular and genetic basis for this type of colon cancer?