CASE REPORT

Interventional Medicine & Applied Science, Vol. 8 (1), pp. 26–28 (2016)

An unusual radiological presentation of mucinous adenocarcinoma of the colon JOANNA SWANN, JAKUB KACZYNSKI* Forth Valley Royal Hospital, Larbert, United Kingdom *Corresponding author: Jakub Kaczynski; Forth Valley Royal Hospital, Stirling Road, Larbert, FK5 4WR, United Kingdom; Phone: 00441324 566000; Fax: 00441324; E-mail: [email protected] (Received: May 4, 2015; Revised manuscript received: January 26 2016; Accepted: January 26 2016) Abstract: We report a case of an elderly patient presenting with the left iliac fossa mass. The provisional diagnosis included an inflammatory diverticular mass or sigmoid colon cancer. Interestingly, computed tomography (CT) of the abdomen and pelvis demonstrated the left incarcerated Spigelian hernia containing an inflamed loop of the colon with signs of an early strangulation. However, at operation, a mucinous tumor was found involving the descending and upper sigmoid colon. The tumor eroded through the anterior abdominal wall, which was excised “en bloc.” In the presented case, CT findings suggestive of a benign etiology were misleading. This potentially could have had significant consequences if the patient was treated conservatively. This case highlights that clinical history and examination remain the core components of a safe surgical practice. Clinical judgment cannot be substituted even by the best quality imaging. Therefore, we feel that it is important to share our experience of the successful management of the presented case. Keywords: colorectal cancer, Spigelian hernia, mucinous adenocarcinoma of colon, computed tomography, diverticular disease

Introduction

the patient was treated conservatively. This case highlights that clinical history and examination are the key components of the surgical practice and cannot be substituted even by the best quality imaging. We feel that it is important to share our experience of the successful management of the presented case.

Colorectal cancer is the 3rd most commonly diagnosed cancer in the United Kingdom. Surgical resection of the primary tumor with locoregional lymph nodes is the mainstay of the treatment [1, 2]. The most common presentation includes change in bowel habit, weight loss, rectal bleeding, anemia, and abdominal pain. However, an abdominal wall invasion that can lead to an abscess formation or presentation with fungating cutaneous deposits has been reported [2]. This is frequently seen with the moderately differentiated mucinous adenocarcinomas, which have a poorer prognosis than nonmucinous colorectal adenocarcinomas [2, 3]. There is no doubt that computed tomography (CT) is a very useful diagnostic resource in patients with an acute and chronic abdominal pain when the diagnosis is unclear. However, in the presented case, CT report was misleading and suggestive of a benign aetiology. This potentially could have had significant consequences if

DOI: 10.1556/1646.8.2016.1.5

Case report An 89-year-old female with a history of recent endoscopic resection of a tubulovillous rectal adenoma (low grade dysplasia) presented with abdominal pain and the left iliac fossa (LIF) mass. She described weight loss over a period of months but denied change in the bowel habit. Other past medical history of note was an abdominal aortic aneurysm (anteroposterior diameter of 23 mm), osteoporosis, macular degeneration, and hiatus hernia. Despite her age, she was living alone independently.

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An unusual radiological presentation

Fig. 1.

The LIF mass

Fig. 2.

On admission, the patient was afebrile with normal observations. Examination of the cardiovascular and respiratory systems was unremarkable. On palpation, the abdomen was soft and nontender. Examination of the LIF revealed a nontender, irreducible, fixed, nonfluctuant, and nonpulsatile firm mass (Fig. 1). The cough impulse was absent, and there were no overlying skin changes. Digital rectal examination was normal. Laboratory tests showed hemoglobin of 103 g/L with the low mean corpuscular volume of 77.8 fL, albumin of 29 g/L, and elevated C-reactive protein of 66 mg/L. Carcinoembryonic antigen (CEA) was elevated at 20.4 μg/L, and CA-125 was within normal range. The remaining biochemical markers including white cell count, liver function tests, amylase, and electrolytes were normal. The urine dip stick was negative. Abdominal x-ray showed a nonspecific bowel gas pattern. Chest x-ray was normal with no free air under the diaphragm. In a view of the above history, the provisional diagnosis included an inflammatory diverticular mass or sigmoid colon cancer. A computed tomography (CT) of the abdomen and pelvis was performed to clarify the nature of this mass and to plan surgical management accordingly. CT demonstrated the left incarcerated Spigelian hernia containing an inflamed loop of descending colon with signs of an early strangulation and extensive diverticulosis (Fig. 2). For that reason, the patient was taken to theatre. Initially, a transverse incision was made over the LIF mass. However, this revealed a large abscess cavity filled with frank pus and raised the suspicion of an underlying malignancy. Therefore, an exploratory laparotomy was performed. At operation, a mucinous tumor was found involving the descending and upper sigmoid colon. The tumor eroded through the anterior abdominal wall, which was excised “en bloc.” Given the contamination of the peritoneal cavity, patient’s age, and mucinous character of the tumor, the primary anastomosis was not performed. Subsequently, the remainder of the colon

Interventional Medicine & Applied Science

An axial image demonstrating reported “Spigelian hernia” in the LIF

was mobilized and swung to the right iliac fossa where an end colostomy was fashioned. The abdominal wall defect was repaired using a Vicryl mesh. Overall, the operation was uneventful, and the patient has made a good postoperative recovery and was discharged. The histopathology report showed moderately differentiated mucinous adenocarcinoma of the colon with no extra mucosal vascular invasion. The abdominal wall histopathology confirmed an abscess formation, but there was no evidence of malignancy. These findings were discussed at the multidisciplinary colorectal meeting, and it was decided that no further treatment was required.

Discussion Given the clinical presentation, few would argue that the complicated diverticular disease was one of the differential diagnoses. Colonic diverticulosis is a very common condition in Western societies and has an increased prevalence with age. It can be found in over 40% of the population over 60 years of age compared with only 2% of the population under 30 [1]. Although the whole colon can be affected, there is a tendency for diverticulosis to occur on the left side, particularly in the sigmoid colon [1]. In the vast majority of cases, the disease remains asymptomatic. However, when symptomatic, it can lead to serious complications including diverticulitis, the formation of abscesses, strictures, gastrointestinal hemorrhage, fistulae, and peritonitis [2]. On the other hand, microcytic anemia and weight loss raised the possibility of a colorectal cancer. Adenocarcinoma affecting large bowel is the most common gastrointestinal malignancy [2]. Presentation may include change in bowel habit, weight loss, rectal bleeding, anemia, and abdominal pain. Surgical resection of the primary tumor with locoregional lymph nodes remains the mainstay of a treatment [2]. Abdominal wall

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Swann, Kaczynski

egy. However, sole reliance on a radiological report can be misleading and potentially dangerous for the management of surgical patients. Therefore, surgeons should remember that radiological reports are not an alternative for the best surgical judgment when managing surgical patients.

invasion occasionally leads to an abscess formation [2]. This is frequently seen with the moderately differentiated mucinous adenocarcinomas [2, 3]. These tumors are often more advanced at diagnosis and have a poorer prognosis than nonmucinous colorectal adenocarcinomas [3]. Additionally, they can recur as fungating skin lesions [4, 5]. Therefore, in the presented case, “en bloc” excision of the invaded abdominal wall with the mucinous tumor was performed in order to avoid future fungating recurrence. The least expected finding, in this case, was a suggestion of the Spigelian hernia, which is very rare and constitutes 0.12% of abdominal wall hernias [6]. The Spigelian hernia occurs through the linea semilunaris at the outer border of the rectus abdominis muscle [6]. It typically presents with an intermittent mass, localized pain, or signs of bowel obstruction [6]. Furthermore, the hernia is usually small and, therefore, has a high risk of strangulation. Hence, surgical repair is the advocated treatment. There is no doubt that CT provides high-quality images with a resolution of less than 1 mm [7, 8]. This is crucial not only when clinical diagnosis is unclear, but often, imaging helps to plan appropriate surgical treatment [8]. However, in the presented case, CT findings suggestive of a benign etiology were misleading. This potentially could have had significant consequences if the patient was treated conservatively. Although CT is an excellent imaging modality, it cannot replace the clinical judgment and surgeon’s expertise.

*** Funding sources: No financial support was received for this study. Authors’ contribution: JS drafted the case report and performed the literature search; JK revised the case report and prepared the figures. All authors read and approved the article. Conflict of interest: The authors declare no conflict of interests.

References 1. Hobson K, Roberts P: Etiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 17, 147–153 (2004) 2. Garden OJ, Bradbury AW, Forsythe JLR, Parks RW (2012): Principles and Practice of Surgery. Elsevier, Edinburgh, London, New York, Oxford, Philadelphia, St. Louis, Sydney, Toronto 3. Kanemitsu Y, Kato T, Hirai T, Yasui K, Morimoto T, Shimizu Y, Kodera Y, Yamamura Y: Survival after curative resection for mucinous adenocarcinoma of the colorectum. Dis Colon Rectum 46, 160–167 (2003) 4. Tan KY, Ho KS, Lai JH, Lim JF, Ooi BS, Tang CL, Eu KW: Cutaneous and Subcutaneous Metastases of Adenocarcinoma of the Colon and Rectum. Ann Acad Med Singapore 35, 585–587 (2006) 5. Llaguna OH, Desai P, Fender AB, Zedek DC, Meyers MO, O’Neil BH, Diaz LA, Calvo BF: Subcutaneous metastatic adenocarcinoma: an unusual presentation of colon cancer-case report and literature review. Case Rep Oncol 3, 386–390 (2010) 6. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, Chowbey PK: Diagnosis and management of Spigelian hernia: a review of literature and our experience. J Minim Access Surg 4, 95–98 (2008) 7. Farr RF, Allisy-Roberts PJ (1996): Physics for Medical Imaging. Bailliere Tindall, Oxford 8. Strömberg C, Johansson G, Adolfsson A: Acute abdominal pain: diagnostic impact of immediate CT scanning. World J Surg 31, 2347–2354 (2007)

Conclusion This case highlights the importance of the core clinical surgical skills. These include history taking, examination, and interpretation of clinical findings supported by appropriate investigations. CT is a very useful diagnostic tool, which also helps to plan appropriate surgical strat-

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Interventional Medicine & Applied Science

An unusual radiological presentation of mucinous adenocarcinoma of the colon.

We report a case of an elderly patient presenting with the left iliac fossa mass. The provisional diagnosis included an inflammatory diverticular mass...
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