The Case Files

Abstract

Figure: Image A.FigureFigureA 41-year-old woman presented to the emergency department with abdominal pain, noting multiple episodes over the past year of intermittent right upper quadrant pain that she described as “achy” and “fullness.” These episodes occurred sporadically with no identifiable exacerbating factors. Associated symptoms included a 20-pound unintentional weight loss over two months with occasional nausea and vomiting. She was a former smoker of 10-pack years and had stopped two months prior to arrival, and she reported drinking two to three glasses of wine a week. She did not have a primary care physician. Her vital signs on arrival were a temperature of 97.7°F, blood pressure of 132/97 mm Hg, heart rate of 98 bpm, 99% pulse ox on room air, respirations of 18 bpm, and weight of 76 kg. A physical exam revealed mild tenderness to deep palpation in the RUQ with appreciable hepatomegaly. Laboratory values were remarkable for a hemoglobin of 12.7 g/dL, mean corpuscular volume of 92, gamma-glutamyl transferase of 382 (9-48 U/L), total bilirubin of 0.6, alkaline phosphatase of 205 (44-147), aspartate aminotransferase of 55 U/L (10-37 U/L), alanine aminotransferase of 33 U/L (8-37 U/L). She was hemoccult-positive on rectal exam. Ultrasound showed multiple lobulated ill-defined masses throughout the liver. (Images A and B.) A CT abdomen/pelvis showed multiple heterogeneously enhancing irregular hepatic masses, with the largest measuring 10.6 x 10.1 x 11.1 cm. (Images C and D.) She was admitted for further evaluation. High Mortality Colorectal carcinoma is a common and lethal disease with around 140,000 cases diagnosed annually in the United States. (UpToDate, May 2, 2018; http://bit.ly/2IPlAS5.) About 56,000 patients die of the disease. Clinical research has shown that patients with a primary care physician have better management of chronic disease, access to preventive care, including cancer screenings, and chronic care of a multitude of medical problems. Advanced cases, like our patient's demonstrated, commonly present with iron-deficient anemia, rectal bleeding, abdominal pain, change in bowel habits, and sometimes an intestinal obstruction or perforation. A study of 388 patients diagnosed with colorectal carcinoma from 2011-2014 found the most common symptoms leading to a diagnostic colonoscopy to be rectal bleeding (37%), abdominal pain (34%), and anemia (23%). (UpToDate, May 2, 2018; http://bit.ly/2IPlAS5.) Clinical manifestations will differ depending on the location of the tumor. A change in bowel habits is more common in left-sided colorectal carcinoma, as is hematochezia. Iron-deficient anemia has been found to be more common in right-sided colorectal carcinoma. (UpToDate, May 2, 2018, http://bit.ly/2IPlAS5; Clin Colorectal Cancer 2016;15[1]:67; http://bit.ly/2KDxe7F.)Figure: Image B.Figure: Image C.The goal of laboratory evaluation is to assess patients' organ function for potential diagnostic and therapeutic procedures, as well as tumor burden. A baseline carcinoembryonic antigen carries a prognostic value. Patients with highly elevated values are associated with more advanced disease. (Anticancer Res 2001;21[4B]:3031.) Colorectal carcinoma metastases are most commonly found in the liver and the lung. Chemotherapy and radiation therapy following surgical resection of the primary tumor, when indicated, remain the mainstay of adjuvant therapy. Approximately 20 percent of patients are diagnosed with metastatic disease at their initial presentation. (UpToDate, May 2, 2018; http://bit.ly/2IPlAS5.) Our patient's colonoscopy showed an ulcerated sigmoid mass. The tumor marker carbohydrate Ag 19-9 was 670 U/mL (0-35). The confirmed diagnosis of metastatic adenocarcinoma with primary colorectal carcinoma was made based on subsequent CT-guided biopsy of the liver, followed by pathological report and a biopsy at the ulcerated sigmoid mass showing high-grade dysplasia. Given the extent and bilobar nature of the metastases, our patient's best option was to start systemic chemotherapy, followed by fully restaging after 12 cycles to determine if she would benefit from liver-directed therapy.Figure: Image D.