Presentation
Represents with generalized abdominal pain, vomiting/dry retching/anorexia for 5 days.
Patient Data
There is a focal segment of sigmoid wall thickening characterizing a solid enhancing mass that extends for 5.5 cm with a 4.0 cm width. This causes diffuse upstream colonic distension with fecal loading. A few adjacent lymph nodes are noted, measuring less than 1 cm in their short diameter. Small amount of free fluid in the pelvis. No free gas in the abdominal cavity. Small bowel is unremarkable. The liver demonstrates a subcapsular ill-defined hypodense nodule measuring 2.7 cm in the segment VI and a tiny 4.7 mm hypodense lesion in the segment IVB, which is too small to characterize. The gallbladder, pancreas, and adrenal glands are unremarkable. Kidneys have normal size and enhancement; there is a tiny non-obstructive calculus in the left kidney upper moiety. No hydronephrosis. Apart from a 1.5 cm right para-aortic lymph node, the retroperitoneum is unremarkable. No suspicious bone lesions. Pleural bases are clear. Conclusion: Features favoring a colonic carcinoma in the sigmoid causing at least partial obstruction and retained upstream fecal loading. Liver lesion in the segment VI is indeterminate within this protocol but may represent hemangioma, and multiphase CT is recommended to characterize.
Case Discussion
The patient underwent to a partial colectomy:
MICROSCOPIC DESCRIPTION: Sections from the sigmoid show an ulcerated moderately differentiated adenocarcinoma composed of irregular glands with a complex cribriform architecture, many with central necrosis and associated calcification. Malignant glands focally infiltrate the pericolic fat and extend beyond the muscularis propria to within 5mm of the serosal surface. The malignant cells have pleomorphic vesicular nuclei and prominent nucleoli. Mitotic figures are frequent. The stroma is desmoplastic and the tumor is associated with a moderate to heavy lymphocytic and neutrophilic infiltrate. Perineural and lymphovascular invasion are not identified. One of twenty eight lymph nodes is involved by metastatic tumor.
DIAGNOSIS: Sigmoid colon: * Moderately differentiated adenocarcinoma, invading through muscularis propria into pericolic tissue (pT3) - Obstructing circumferential tumor 60mm in length - Clear of serosa - Well clear of margins - No perineural or lymphovascular invasion - 1 our of 28 lymph nodes involved by tumor (1/28). - pT3 pN1c AJCC stage IIIB.
IMMUNOHISTOCHEMISTRY Mismatch repair proteins MLH1 POSITIVE PMS2 POSITIVE MSH2 POSITIVE MSH6 POSITIVE There is normal expression of mismatch repair proteins in tumor cells, indicating that the tumor is mismatch repair proficient (microsatellite stable, MSS). BRAF V600E NEGATIVE
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