A Rare Case Report: 23-Year-Old Man with Ascending
Colon Cancer with Napkin’s Ring Appearance
Dwi Novia
Lestari1, Mohammad Arifin2*
Faculty of Medicine, Tarumanagara University, Jakarta1,
Department of Surgery, RSUD RAA Soewondo Pati, Pati2
Email: arifin.spb@gmail.com
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KEYWORDS |
ABSTRACT |
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Colorectal
Cancer, Napkin’s Ring, Laparotomy, Hemicolectomy |
Colorectal
cancer is a malignancy of the large intestine resulting from changes in the
colon epithelial cells. Although incidence rates in developed countries have
decreased due to improved screening and treatment, colorectal cancer remains
a leading cause of cancer-related deaths globally. In Indonesia, colorectal
cancer ranks as the third most common type, with a notably higher incidence
among younger populations compared to developed nations. This case report
focuses on a rare instance of ascending colon cancer in a 23-year-old man, a
demographic less commonly affected by this condition. The purpose of this
case report is to highlight the atypical presentation and management of colon
cancer in a young adult, providing insights into diagnostic and therapeutic
approaches in this context. The case was selected to underscore the
differences in colorectal cancer presentation and management in younger
patients, contrasting with more typical cases. The main findings include the
patient’s initial presentation with ascension colon cancer, the intervention
of right hemicolectomy, and the subsequent significant improvement in his condition
following treatment. This case emphasizes the importance of considering
colorectal cancer in young patients presenting with gastrointestinal symptoms
and highlights the need for awareness and timely intervention to improve
outcomes. It suggests that even rare cases of colorectal cancer in younger
individuals can be effectively managed with appropriate surgical and
pharmacological therapy. |
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DOI: |
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Corresponding Author: Mohammad Arifin*
Email: arifin.spb@gmail.com
INTRODUCTION
Colon cancer is a malignancy that arises in
the large intestine due to changes in the epithelial cells of the colon
Colorectal cancer is predominantly
sporadic, accounting for about 70% of cases. Inherited genetic mutations
contribute to 3% to 5% of cases, while 20% to 25% have a family history without
identifiable genetic mutations. Symptoms of colorectal cancer vary depending on
the disease stage. Early symptoms may include hematochezia, which might not
alter stool appearance but can be detected through occult blood tests. As the
disease progresses, symptoms may include bloody stools, intestinal obstruction,
abdominal mass, and systemic symptoms such as cachexia, anemia, and weight loss
Standard treatment involves surgical
resection of the tumor, with the specific approach depending on tumor location
and stage. Adjuvant chemotherapy is recommended for advanced cases, and
systemic therapy is used for metastatic disease
This case report aims to document the
presentation and management of a 23-year-old man diagnosed with ascending colon
cancer, from initial history taking through to the treatment administered.
METHOD
Samples were taken from a 23-year-old man with
Ascending Colon Cancer. The case is described using a descriptive case study
method starting from history taking, physical examination, evaluation, and diagnosis
to intervention management given to patients qualitatively
RESULT AND DISCUSSION
A 23-year-old patient came to the RAA Soewondo
Pati Regional Hospital with a chief complaint of right abdominal pain for three
days before hospital admission. The initial pain had been felt 8 months ago.
The pain feels like being stabbed and it comes and goes. The pain feels worse
with any kind of activity and gets better with rest. Since the abdominal pain,
the patient had sought treatment at the clinic but the pain was still there and
was getting worse. The symptoms were accompanied by nausea and vomiting, flatus
(+), defecation (+), defecation (+) thick consistency no mucus and blood, but 4
months ago the stools were watery and accompanied by fresh blood. The patient
had a history of dyspepsia and usually takes Proton Pump Inhibitor (PPI)
medication to treat his stomach complaints. The patient also said that he often
drank alcoholic drinks and smoked every day since he was a teenager.
From the physical examination, it was found
that the patient appeared moderately ill, with blood pressure 120/80 mmHg, HR:
82x/minute, temperature: 36.6 C, and SpO2: 98%. Abdominal examination is flat,
not distended, bowel sounds (+). On percussion tympanic, tapping pain (+) in
the lumbar extra region, iliac extra, and on palpation tenderness (+) in the
lumbar extra region, iliac extra. We also did a rectal toucher test. The anal
sphincter tone is good, clamps firmly, the recti ampulla does not collapse, the
mucosa feels smooth and warm, no mass can be felt when pushing, and there is no
tenderness. There are no faeces on the gloves and no blood or mucus spots.
On further examination, an increase in
leukocytes (17.6 x 103 / uL), a decrease in erythrocytes (3.0x106/uL), a
decrease in haemoglobin (10 g/dL), a decrease in hematocrit (32.3%), an
increase in platelets (578x103/uL), an increase in APTT were found. (54.1
seconds), decreased albumin (3.2 g/dL). On radiological examination, the colon
in Loop found contrast agent entering through the anus filling the rectum to
the ascending colon, passage of the contrast agent was slightly obstructed in
the ascending colon, narrowing the ascending colon with irregular edges,
napkin's ring type, haustra and incisura appeared good.
Figure
1: Intra Luminary Tumor Appears in the Ascending
Colon
Figure
2: post hemicolectomy laparotomy
Then this patient was given therapy in the form
of Ringer’s Lactate: Futolit 1:1, meropenem injection 1gr/8 hours,
metronidazole injection 500 mg/8 hours, esola injection 1x40 mg, pamol 3x500 mg
then this patient underwent a right hemicolectomy laparotomy and after
follow-up for a few weeks there was significant improvement.
Colon cancer is a malignancy that
originates from the colon tissue, consisting of the colon (the longest part of
the large intestine) and/or the rectum (the last small part of the large
intestine before the anus). Together with rectal cancer, colon cancer occupies
the third highest position in cancer incidence worldwide and is the third most
common cause of death from cancer incidence worldwide.1,2,3
Epidemiologically,
the incidence of colon cancer in several developed countries has decreased over
the last few decades due to more optimal screening and treatment systems.
However, colon cancer together with rectal cancer is still the third highest
cause of death in cancer cases worldwide. In 2018 alone, there were 1.8 million
newly diagnosed cases of colorectal cancer. 4 Globally, there were around 1.8
million cases of colorectal cancer reported in 2018 and this figure contributed
10.2% of the total cancer cases. The incidence varies quite widely between
countries, with the highest rates reported in Australia and New Zealand, while
the lowest rates are reported in South-Central Asia.1.4 Colorectal cancer in
Indonesia is the 3rd most common type of cancer with an incidence rate of 1.8
cases per 100,000 population. The characteristics of colorectal cancer patients
in Indonesia are somewhat different from those in developed countries. In
Indonesia, 51% of all sufferers are under 50 years old and 28.17% of patients are
under 40 years old. The increasing number of colorectal cancers in Indonesia is
thought to be related to the Westernized lifestyle of society, especially in
big cities. 5 In this case, the patient was a 23-year-old man who had a fairly
rare case, namely colorectal cancer.
Most
colon cancers are sporadic (70%). The condition, with a known inherited genetic
mutation, occurs in 3% to 5% of cases. About 20% to 25% of patients have a
family history of colon cancer but no inherited mutation can be identified.
Risk factors for colon cancer include the following; age: the average age of
diagnosis of sporadic colon cancer is over 65 years, family history: colon
cancer in family members increases a person's risk of developing the disease,
inherited colon cancer-related mutations, adenomas on colonoscopy examination:
the risk of cancer is most significant with villous adenomas and sessile
serrated polyps, a history of inflammatory bowel disease (IBD), environmental
and lifestyle factors: alcohol consumption, smoking, obesity, a diet rich in
processed red meat, insulin resistance, a history of previous radiation, and
immunosuppression all increase the risk of this malignancy.6,7,8 In this case,
the patient had a history of quite massive alcohol and smoking consumption, as
well as an unhealthy lifestyle which may have caused the patient's risk of
colon cancer to increase.
The
pathophysiology of colon cancer, namely, begins when there is a transition from
normal colonic epithelium to dysplasia involving genetic changes that
accumulate over time, ultimately causing carcinoma. Colon cancer can develop
through 3 main genetic pathways: chromosomal instability (CIN), MMR, and CpG
island methylator phenotype (CIMP). These pathways do not stand alone but
overlap with each other.9 Types of colorectal carcinoma include polypoid, with
the characteristics of growing protruding into the intestinal lumen in the
shape of a cauliflower, usually appearing in the cecum and descending colon.
Scirrhous colorectal cancer, with mass characteristics that can cause narrowing
resulting in stenosis and symptoms of stenosis and symptoms of obstruction, is
usually found in the descending colon, sigmoid and rectum. Ulcerative type is usually
characterized by necrosis in the central part of the colon carcinoma which can
cause malignant ulcers.3 In this case, a radiological examination was carried
out, the colon in Loop showed narrowing in the ascending colon with irregular
edges, napkin's ring type, haustra and incisura looked good. This may be a type
of Scirrhous type of colorectal cancer because there is visible narrowing and
stenosis so there are symptoms of obstruction, which is characteristic of the
Scirrhous type of colorectal carcinoma.
Early
colorectal cancer often has no symptoms. As the disease progresses, the
following symptoms will generally appear. The following are some of the
symptoms that can arise, namely hematochezia: In small amounts of hematochezia,
the stool generally does not show visible changes, but the stool occultation
test can be positive; bloody stools, mucus, or jam-like stools may appear if
there is a lot of blood in the stool. Intestinal obstruction: Often a feature
of advanced colorectal cancer; abdominal tenderness, flatulence, nausea,
vomiting, fatigue, and loose stools will occur if intestinal obstruction is
caused by an enlarged mass. Abdominal mass: Usually occurs in right colon
cancer; These symptoms include enlargement of the mass to a certain extent, a
palpable abdominal mass. Systemic symptoms generally do not show obvious
symptoms in the early stages, so the course of the disease is relatively long,
causing tumour proliferation, cachexia, anaemia, weight loss and other
symptoms. Due to the different anatomical and physiological functions of the
colon and rectum, the clinical manifestations of tumours in different
anatomical locations are also different. In general, abdominal masses and
systemic symptoms are more common in right colon cancer, bloody stools and
obstruction are more common in left colon cancer, and changes in bowel habits
are more common in rectal cancer.10,11 General physical examination should
focus on signs of metastatic disease in all patients, with examinations
adjusted to the patient's condition. A focused abdominal examination should be
performed to evaluate tenderness, palpable masses, hernias, previous scars, and
organomegaly. Rectal examination is essential and should not be missed in all
patients with suspected gastrointestinal malignancy. In addition to checking
for signs of malignancy, a rectal examination is also valuable in providing
details about sphincter tone and continence.12 In this case, the patient had
experienced right-sided abdominal pain for 3 days before hospital admission.
The initial pain had been felt 8 months ago. The pain feels like being stabbed
and comes and goes. The pain feels worse with activity and gets better with
rest. Since the complaints first appeared, the patient had sought treatment at
the clinic but the complaints were still felt and were getting worse.
Complaints accompanied by nausea and vomiting, flatus (+), urination (+), and bowel
movements (+) of solid consistency. We also did a rectal examination test. The
anal sphincter tone is good, clamps firmly, the recti ampulla does not
collapse, the mucosa feels smooth, and warm, no mass can be felt when pushing, and
there is no tenderness. There is no faeces on the
gloves, and no blood or mucus spots.
In
further evaluations, laboratory examinations can be carried out in the form of
complete blood count, RFT, CEA (tumour marker substance), and disguised stool
examination (benzidine test). Colon photo with barium/double contrast (Colon in
the loop), endoscopy: Proctoscopy can see 8-10 cm from the anus,
Rectosigmoidoscopy: 20-25 cm from the anus, Colonoscopy of the entire colon,
looking at the more proximal side of the colon, biopsy. The sensitivity of
colonoscopy is approximately 94.7% if performed by an experienced operator and
with good bowel preparation. Ultrasound, abdominal CT scan, CXR are usually
seen to see if there are metastases. PET/CT can be performed to detect primary
cancer lesions, metastatic lesions, the extent of the lesion, and determine the
stage. 13 In this patient, a supporting examination in the form of a complete
blood test found an increase in leukocytes (17.6 x 103 / uL), a decrease in
erythrocytes (3.0x106/uL). uL), decreased haemoglobin (10 g/dL), decreased
haematocrit (32.3%), increased platelets (578x103/uL), increased APTT (54.1
seconds), decreased albumin (3.2 g/dL). And a radiological examination in the
form of a colon in loop was also carried out, it was found that the contrast
agent entered through the anus and filled the rectum to the ascending colon,
the passage of the contrast agent was slightly obstructed in the ascending
colon, there was narrowing in the ascending colon with irregular edges,
napkin's ring type, haustra and incisura looked good, there is an image of an
intra-luminary tumor in the ascending colon.
Surgical resection is standard therapy for
colorectal cancer. The type of resection, extent of lymphadenectomy and
specific technique depend on the location and grade of the tumor. Adjuvant
chemotherapy is indicated if severe colorectal cancer is present. Patients with
metastases usually receive systemic therapy. Radiation therapy is rarely used
Surgical intervention is essential in the management of colon cancer,
addressing both the diagnostic and therapeutic aspects of the disease. The main
goal of surgical procedures for colon cancer is to completely remove the tumor
while maintaining optimal bowel function and minimizing complications. 13
Surgery for colon cancer resection can be performed laparoscopically or open
surgically. Surgery is usually performed for localized colon cancer (stages
I–III), but is also thought to have the potential to treat colon cancer with
minimal liver or lung metastases (stage IV). 1 Medical treatment can include
adjuvant, neoadjuvant, or palliative chemotherapy as well as administering
biological agents or targeted therapy. Chemotherapy is recommended for stage
III colon cancer patients and some high-risk stage II colon cancer patients.
Patients who are at high risk are patients with <12 lymph nodes removed,
poorly differentiated tumors, vascular/lymphatic/perineural invasion, or tumours
with perforation or obstruction. Over the past two decades, the standard
chemotherapy has been 5-fluorouracil combined with levamisole or leucovorin.
This therapy has been proven to reduce cancer recurrence rates within 5 years
and mortality rates by 30%. However, currently, there are also other effective
regimens, such as oxaliplatin, capecitabine, and irinotecan. Biological therapy
used for colon cancer is monoclonal antibodies that can fight vascular
endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR),
as well as kinase inhibitors and decoy receptors for VEGF. Examples are
bevacizumab, cetuximab, aflibercept, panitumumab, and regorafenib.14,15,16 In
this case, the patient underwent treatment in the form of Ringer’s Lactate: Futrolit
1:1, meropenem injection 1gr/8 hours, metronidazole injection 500 mg/8 hours, Isola
injection 1x40mg, pamol 3x500 mg. In accordance with previous research, the
main therapy is surgical treatment, which in this case was surgical therapy in
the form of a hemicolectomy laparotomy.
CONCLUSION
The conclusion from the above quote is that
colon cancer is a type of cancer that originates in the colon or rectal tissue
and is one of the cancers with the highest incidence and mortality rates in the
world. Although the incidence of colon cancer in some developed countries has
decreased thanks to more optimal screening and treatment systems, it remains
the third highest cause of death from cancer in the world.
Risk factors for colon cancer include
advanced age, family history, cancer-related genetic mutations, adenomas on
colonoscopy examinations, history of inflammatory bowel disease, as well as
environmental and lifestyle factors such as alcohol consumption, smoking,
obesity, and unhealthy diet. The pathophysiology of colon cancer starts from
normal colon epithelial changes to dysplasia which involves genetic changes
that eventually lead to carcinoma.
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