Failure of 3 different methods and biopsy sites to diagnose a patient with invasive colorectal cancer

Abstract

Rationale: Colorectal cancer is one of the most commonly diagnosed cancers worldwide, and the majority arise from neoplastic adenomatous polyps. Bladder involvement in colorectal cancer is uncommon and found in approximately 3% of the cases, most commonly in sigmoid and rectal tumors and the diagnosis is classically based on biopsies of affected tissues. Patient concerns: A 68-year-old male with no significant past medical history underwent diagnostic colonoscopy for abdominal distension and constipation with positive fecal occult blood test ordered by the primary care physician. Diagnosis: Colonoscopy showed a sigmoid mass with biopsy finding of tubulovillous adenoma. Laparoscopy was performed for sigmoid colonic resection, but as the mass was large, a diverting loop colostomy and multiple biopsies were performed revealing tubulovillous adenoma again. Postoperative workup revealed right hydronephrosis, and cystoscopy was performed confirming bladder wall invasion with biopsies showing benign bladder wall tissue with no evidence of dysplasia or malignancy. Furthermore, computed tomography (CT)-guided core-needle biopsies of the colonic mass were performed but revealed adenomatous colonic mucosa without evidence of carcinoma. Intervention: Definitive surgical en bloc excision of the tumor and anterior bladder wall was performed with urology team until grossly free margins were attained. Final pathology revealed well-differentiated mucinous adenocarcinoma arising from a preexisting tubulovillous adenoma with direct invasion of the bladder wall. Outcomes: The patient's postoperative recovery was uneventful, and he was discharged 2 weeks postoperatively with planned adjuvant chemotherapy. Lessons: This case represents a classical presentation of invasive colorectal cancer. Perioperative workup, however, was confounded by failure of open, cystoscopic, and CT-guided biopsies to establish a tissue diagnosis for directed therapy. Upon literature review, evidence exists to support our approach to this unique dilemma.

Treatment efficacy and prognosis analysis in locally advanced or metastatic colorectal cancer patients with hydronephrosis

“…Zhang et al (4) showed that among 148 patients who received adjuvant chemotherapy or radiotherapy postoperatively, 13 patients developed hydronephrosis, of which five were considered to be caused by benign factors (e.g., surgical or radiotherapy factors), and eight patients were diagnosed with recurrent metastasis. The pelvic cavity is the most common site of recurrence of peritoneal or abdominal lymph node metastasis (5). The tumor mass can obstruct the upper urinary tract via compression or direct invasion of the ureters, causing hydronephrosis without any symptoms or manifesting as low back pain, renal failure, or urinary tract infection, which can be diagnosed based on computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (5).…”

“…The pelvic cavity is the most common site of recurrence of peritoneal or abdominal lymph node metastasis (5). The tumor mass can obstruct the upper urinary tract via compression or direct invasion of the ureters, causing hydronephrosis without any symptoms or manifesting as low back pain, renal failure, or urinary tract infection, which can be diagnosed based on computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (5). Using CT scans, Brown et al (6) found that a peritoneal centred focal tumor mass was the most common cause of postoperative hydronephrosis, especially in patients with R1 or R2 resection, or in those at stage pT4 with peritoneal or adjacent organ invasion.…”