Atypical Presentation of Colon Adenocarcinoma: A Case Report
Atypical Presentation of Colon Adenocarcinoma: A Case Report
Introduction: Adenocarcinoma of the colon is the most common histopathological type of colorectal cancer. In Western Europe and the United States, it is the third most common type and accounts for 98% of cancers of the large intestine. In Uganda, as elsewhere in Africa, the majority of patients are elderly (at least 60 years old). However, more recently, it has been observed that younger patients (less than 40 years of age) are presenting with the disease. There is also an increase in its incidence and most patients present late, possibly because of the lack of a comprehensive national screening and preventive health-care program. We describe the clinicopathological features of colorectal carcinoma in the case of a young man in Kampala, Uganda.
Case presentation: A 27-year-old man from Kampala, Uganda, presented with gross abdominal distension, progressive loss of weight, and fever. He was initially screened for tuberculosis, hepatitis, and lymphoma, and human immunodeficiency virus/acquired immunodeficiency syndrome infection. After a battery of tests, a diagnosis of colorectal carcinoma was finally established with hematoxylin and eosin staining of a cell block made from the sediment of a liter of cytospun ascitic fluid, which showed atypical glands floating in abundant extracellular mucin, suggestive of adenocarcinoma. Ancillary tests with alcian blue/periodic acid Schiff and mucicarmine staining revealed that it was a mucinous adenocarcinoma. Immunohistochemistry showed strong positivity with CDX2, confirming that the origin of the tumor was the colon.
Conclusions: Colorectal carcinoma has been noted to occur with increasing frequency in young adults in Africa. Most patients have mucinous adenocarcinoma, present late, and have rapid disease progression and poor outcome. Therefore, colorectal malignancy should no longer be excluded from consideration only on the basis of a patient's age. A high index of suspicion is important in the diagnosis of colorectal malignancy in young African patients.
Adenocarcinoma of the colon is the most common histopathological type of colorectal carcinoma. It ranks fourth in men and third in women in Western Europe and the US and overall accounts for 98% of cancers of the large intestine. This tumor has been largely associated with a 'Western' lifestyle (obesity, lack of physical activity, consumption of diets low in fruit and vegetables, and overconsumption of red meat), hence its predominance in affluent societies. In addition to lifestyle, pre-malignant conditions such as familial adenomatous polyposis coli syndrome and inflammatory bowel disease are important associated factors.
In sub-Saharan Africa, evidence shows that the incidence of adenocarcinoma of the colon is rising and this has been attributed to the change in lifestyle as a result of globalization. In Uganda, the Kampala Cancer Registry in the Department of Pathology, School of Biomedical Sciences, College of Health Sciences, Makerere University, which covers a population of two million people in Kyadondo County, has shown an increased trend in the past three decades. In the period from 1960 to 1997, incidences have increased from three to 6.8 per 100,000 in women and from 2.7 to 6.6 per 100,000 in men. This trend has been observed in other low-income countries where the incidence was once low.
The low incidence in Africans as compared with Caucasians results from consumption of diets rich in fiber, which is a common practice, and the rarity of the pre-malignant familial polyposis syndromes and inflammatory bowel disease (ulcerative colitis and Crohn's disease). However, urbanization and civilization have led to changes in dietary habits and to less exercise. This might be the reason for this rising trend.
Diagnostic workup is largely in line with the presenting features of the patients, and the diagnosis is usually made on the basis of colonoscopy and biopsy. However, when the presentation is unusual (as in our patient), diagnosis is difficult. We describe an atypical presentation of adenocarcinoma of the colon in a young man and discuss the challenges of diagnosis in a resource-limited setting.
Abstract and Introduction
Abstract
Introduction: Adenocarcinoma of the colon is the most common histopathological type of colorectal cancer. In Western Europe and the United States, it is the third most common type and accounts for 98% of cancers of the large intestine. In Uganda, as elsewhere in Africa, the majority of patients are elderly (at least 60 years old). However, more recently, it has been observed that younger patients (less than 40 years of age) are presenting with the disease. There is also an increase in its incidence and most patients present late, possibly because of the lack of a comprehensive national screening and preventive health-care program. We describe the clinicopathological features of colorectal carcinoma in the case of a young man in Kampala, Uganda.
Case presentation: A 27-year-old man from Kampala, Uganda, presented with gross abdominal distension, progressive loss of weight, and fever. He was initially screened for tuberculosis, hepatitis, and lymphoma, and human immunodeficiency virus/acquired immunodeficiency syndrome infection. After a battery of tests, a diagnosis of colorectal carcinoma was finally established with hematoxylin and eosin staining of a cell block made from the sediment of a liter of cytospun ascitic fluid, which showed atypical glands floating in abundant extracellular mucin, suggestive of adenocarcinoma. Ancillary tests with alcian blue/periodic acid Schiff and mucicarmine staining revealed that it was a mucinous adenocarcinoma. Immunohistochemistry showed strong positivity with CDX2, confirming that the origin of the tumor was the colon.
Conclusions: Colorectal carcinoma has been noted to occur with increasing frequency in young adults in Africa. Most patients have mucinous adenocarcinoma, present late, and have rapid disease progression and poor outcome. Therefore, colorectal malignancy should no longer be excluded from consideration only on the basis of a patient's age. A high index of suspicion is important in the diagnosis of colorectal malignancy in young African patients.
Introduction
Adenocarcinoma of the colon is the most common histopathological type of colorectal carcinoma. It ranks fourth in men and third in women in Western Europe and the US and overall accounts for 98% of cancers of the large intestine. This tumor has been largely associated with a 'Western' lifestyle (obesity, lack of physical activity, consumption of diets low in fruit and vegetables, and overconsumption of red meat), hence its predominance in affluent societies. In addition to lifestyle, pre-malignant conditions such as familial adenomatous polyposis coli syndrome and inflammatory bowel disease are important associated factors.
In sub-Saharan Africa, evidence shows that the incidence of adenocarcinoma of the colon is rising and this has been attributed to the change in lifestyle as a result of globalization. In Uganda, the Kampala Cancer Registry in the Department of Pathology, School of Biomedical Sciences, College of Health Sciences, Makerere University, which covers a population of two million people in Kyadondo County, has shown an increased trend in the past three decades. In the period from 1960 to 1997, incidences have increased from three to 6.8 per 100,000 in women and from 2.7 to 6.6 per 100,000 in men. This trend has been observed in other low-income countries where the incidence was once low.
The low incidence in Africans as compared with Caucasians results from consumption of diets rich in fiber, which is a common practice, and the rarity of the pre-malignant familial polyposis syndromes and inflammatory bowel disease (ulcerative colitis and Crohn's disease). However, urbanization and civilization have led to changes in dietary habits and to less exercise. This might be the reason for this rising trend.
Diagnostic workup is largely in line with the presenting features of the patients, and the diagnosis is usually made on the basis of colonoscopy and biopsy. However, when the presentation is unusual (as in our patient), diagnosis is difficult. We describe an atypical presentation of adenocarcinoma of the colon in a young man and discuss the challenges of diagnosis in a resource-limited setting.