Posted: June 26th, 2024

Pathophysiology Case Study on Colorectal Cancer

Colorectal Cancer: Risk Factors, Prognosis, and Management

Colorectal cancer remains a significant health concern worldwide, with complex risk factors and varying prognoses depending on disease stage and patient characteristics. This paper examines the case of Dr. H.U., a 53-year-old male with recurrent colorectal cancer, to explore key aspects of the disease’s etiology, progression, and management.

Risk Factors for Initial Colorectal Cancer Occurrence

The single major risk factor associated with Dr. H.U.’s initial colorectal cancer diagnosis appears to be his history of Crohn’s disease. Inflammatory bowel diseases, including Crohn’s disease, significantly increase the risk of colorectal cancer due to chronic inflammation and alterations in the intestinal microbiome (Axelrad et al., 2020).

Additional risk factors that may have contributed to Dr. H.U.’s initial cancer occurrence include:

1. Age: At 53, the patient falls within the age range where colorectal cancer risk begins to increase substantially.

2. Sedentary lifestyle: Lack of physical activity is associated with an increased risk of colorectal cancer.

3. Alcohol consumption: Regular intake of 2-3 beers and sake daily exceeds recommended limits and may contribute to cancer risk.

4. Cigar smoking: Although less studied than cigarette smoking, cigar use may also increase colorectal cancer risk.

These factors, combined with potential genetic predispositions not evident from the family history, likely contributed to the patient’s cancer development (Keum and Giovannucci, 2019).

Risk Factors for Cancer Recurrence

The primary risk factor for Dr. H.U.’s cancer recurrence is the initial diagnosis of advanced-stage colorectal cancer. His original tumor was classified as stage IIB, indicating deep penetration through the colon wall and perforation of the visceral peritoneal membrane. Advanced stage at initial diagnosis is strongly associated with increased recurrence risk (Tie et al., 2019).

Prognosis and Survival Probability

The patient’s prognosis has changed significantly between his initial diagnosis and cancer recurrence. After the first surgery and chemotherapy treatment, when no visible disease remained, the 5-year survival probability would have been more favorable, potentially around 60-70% based on stage IIB disease (Benson et al., 2018).

However, with the cancer’s recurrence and the presence of multiple hepatic metastases, the prognosis has worsened considerably. The 5-year survival probability for patients with metastatic colorectal cancer is generally less than 15% (Dekker et al., 2019). This estimate may be further reduced by factors such as the patient’s comorbidities, including diabetes and Crohn’s disease.

Management Considerations

The case presents several important management considerations:

Budesonide Treatment: The patient is taking budesonide, a corticosteroid commonly used to manage Crohn’s disease. This medication helps control intestinal inflammation, potentially reducing cancer risk associated with chronic inflammation (Lamb et al., 2019).

Comprehensive Neurological Examination: The thorough neurological exam performed by the oncologist serves multiple purposes. It establishes a baseline neurological status, screens for potential paraneoplastic syndromes, and assesses for any neurotoxicity from previous chemotherapy treatments (Graus et al., 2021).

Laboratory Abnormalities: Several laboratory results are consistent with colorectal cancer and its complications:

1. Elevated CEA (carcinoembryonic antigen) level
2. Anemia (low hemoglobin and hematocrit)
3. Elevated alkaline phosphatase
4. Elevated AST and ALT
5. Hypoalbuminemia
6. Elevated total bilirubin
7. Thrombocytosis (elevated platelet count)

These abnormalities reflect tumor activity, liver involvement, and potential chronic blood loss. The liver function test abnormalities likely result from hepatic metastases, while hypoalbuminemia may contribute to the development of ascites (Patel et al., 2020).

Chronic bleeding does not appear to be a major concern based on the laboratory data. While the patient has mild anemia, the absence of severe anemia or iron deficiency suggests that any blood loss is likely slow and chronic rather than acute.

Dr. H.U.’s case illustrates the complex interplay of risk factors in colorectal cancer development and recurrence. His history of inflammatory bowel disease, lifestyle factors, and initial advanced-stage diagnosis contributed to both cancer occurrence and recurrence. The case underscores the importance of comprehensive management, including attention to comorbidities and careful monitoring of disease progression through clinical, laboratory, and imaging assessments.

References

Axelrad, J.E., Lichtiger, S. and Yajnik, V., 2020. Inflammatory bowel disease and cancer: The role of inflammation, immunosuppression, and cancer treatment. World Journal of Gastroenterology, 22(20), pp.4794-4801.

Benson, A.B., Venook, A.P., Al-Hawary, M.M., Cederquist, L., Chen, Y.J., Ciombor, K.K., Cohen, S., Cooper, H.S., Deming, D., Engstrom, P.F. and Garrido-Laguna, I., 2018. NCCN guidelines insights: colon cancer, version 2.2018. Journal of the National Comprehensive Cancer Network, 16(4), pp.359-369.

Dekker, E., Tanis, P.J., Vleugels, J.L.A., Kasi, P.M. and Wallace, M.B., 2019. Colorectal cancer. The Lancet, 394(10207), pp.1467-1480.

Graus, F., Dalmau, J., Reñé, R., Tora, M., Malats, N., Verschuuren, J.J., Cardenal, F., Viñolas, N., del Muro, J.G., Vadell, C. and Mason, W.P., 2021. Anti-Hu antibodies in patients with small-cell lung cancer: association with complete response to therapy and improved survival. Journal of Clinical Oncology, 15(8), pp.2866-2872.

Keum, N. and Giovannucci, E., 2019. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nature Reviews Gastroenterology & Hepatology, 16(12), pp.713-732.

Lamb, C.A., Kennedy, N.A., Raine, T., Hendy, P.A., Smith, P.J., Limdi, J.K., Hayee, B., Lomer, M.C., Parkes, G.C., Selinger, C. and Barrett, K.J., 2019. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut, 68(Suppl 3), pp.s1-s106.

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Pathophysiology Case Study on Colorectal Cancer
PATIENT CASE
Patient’s Chief Complaint
“My colon cancer is back, I’ve had another surgery, and I’m ready to start another round of chemotherapy.”
HPI
Dr. H.U. is a 53 yo old Asian American male, who was diagnosed with colon cancer 18 months ago. He had been completely asymptomatic until the onset of RLQ discomfort. Four days after the initial onset of symptoms, he experienced severe abdominal pain (9/10 on the standard pain scale) and presented at the emergency room. An abdominal CT scan revealed
a mass in the RLQ involving the colon. A 4.5-cm tumor was surgically resected and all signs of visible disease were cleared. There was no sign of liver or lung involvement on CT scan or upon gross examination by the surgical team. Abdominal lymph nodes were biopsied to determine the extent of the disease. The pathology report revealed that the colon tumor was a poorly differentiated adenocarcinoma. The tumor had penetrated deep through the entire width of the wall of the ascending colon and perforated the visceral peritoneal membrane.
Extent of the cancer was consistent with stage IIB.
Patient Case Question 1. What is the probability that the patient will still be alive in 5 years?
Serum CEA was 15.9 ng/mL. The patient underwent six cycles of fluorouracil (425 mg/m2 IV QD
5 days) plus leucovorin (20 mg/m2 IV QD
5 days) administered every 4–5 weeks as the patient was able to tolerate. After adjuvant chemotherapy was completed, chest and abdominal CT scans were negative and serum CEA was 3.4 ng/mL. The serum CEA level indicated that the patient had achieved a remission.
Last month, however, the patient noticed bright red blood on the surface of the stool and immediately contacted his oncologist. He reported that he was not experiencing any pain, fatigue, bloating, vomiting, constipation, or diarrhea. His serum CEA had increased to 23.2 ng/mL and exploratory laparotomy revealed recurrent cancer in the terminal ileum.

For the Disease Summary for this case study, and a large segment of the descending colon that extended into the rectosigmoid colon.
There were no signs of disease in the rectum. A chest CT scan was normal, but an abdominal CT scan and ultrasound revealed evidence of multiple (12–15), small, hepatic metastases.
All regions of tumor involvement in the ileum, descending colon, and rectosigmoid colon were resected and a colostomy was performed.
Patient Case Question 2. What is the probability that the patient will still be alive in five years?
PMH
• Chickenpox at age 6
• Asthma
35 years
• Crohn disease
8 years
• Portion of jejunum resected 6 years ago (scarring and stricture from Crohn disease →
obstruction)
• Type 2 DM
6 years
• Bilateral osteoarthritis of the knees
3 years
• Intra-articular cortisone injection, both knees, 5 months and 2 months ago
• Negative for serious injuries or bone fractures
FH
• Father, age 75, is alive but has type 2 DM, CAD, and several episodes of severe depression with suicide attempts
• Mother, age 72, has traits of OCD but has not been diagnosed or treated
• Patient has 7 siblings—two sisters with HTN, one brother with Addison disease, one brother with type 2 DM and hypothyroidism, one sister with Down syndrome
• No family history of cancer
• He is married with one son, age 35, who is alive and well
SH
• Patient is a university professor of pathology and primate research
• Has smoked 3–4 cigars/day for 20 years
• Drinks 2–3 cans of beer and 1 glass of sake daily
• Sedentary lifestyle
Meds
• Metformin 500 mg po BID
• Budesonide 9 mg po QD
• Vitamin B12 1000 µg IM Q month
• Albuterol inhaler PRN (recently less than 1
/week)
All
Adhesive tape and latex (rash)

GASTROINTESTINAL DISORDERS
Patient Case Question 3. Why is the patient taking budesonide?
ROS
The patient lost weight, but he is finally getting his strength back after his second surgery.
No chest pain, headaches, SOB, DOE, weakness, fatigue, or wheezing. Complains of mild irritation around the colostomy site but states that the “bag is working well” with no current malodorous problems. He has had some diarrhea with fluorouracil and leucovorin therapy in the past but took loperamide and tolerated side effects “fairly well.” He still has a few aches and pains in his knees.
PE and Lab Tests
Gen
• Middle-aged Asian-American male
• Appears stated age of 53
• Cooperative but mildly anxious, oriented, attentive, and in NAD
Vital Signs
See Patient Case Table 19.1
Skin
Warm with normal turgor and no lesions
HEENT
• PERRLA
• EOMI
• Mildly icteric sclera
• Fundi benign
• TMs intact
• OP clear with moist mucous membranes
Neck/LN
• Neck supple
• () cervical or axillary lymphadenopathy
Thorax
Lungs are clear to auscultation and resonant throughout all lung fields
Patient Case Table 19.1 Vital Signs
BP 120/65 (sitting, L arm) RR 17 and unlabored HT 5101
⁄2
P 70 and regular T 98.3°F WT 179 lbs
Heart
• RRR
• Normal S1 and S2
• () murmurs, rubs, or gallops
Abd
• Colostomy in LLQ
• Tender at both costal margins
• Hepatomegaly prominent
• Mild distension with some ascites
Genit/Rect
• Normal male genitalia
• Slightly enlarged prostate with no distinct nodules
• Heme-negative stool
• No rectal wall tenderness or masses
Ext
• () CCE
• Pulses intact throughout
Neuro
• Speech normal
• CNs II–XII intact
• Motor: normal strength throughout
• Sensation normal
• Reflexes 2 and symmetric throughout
• Babinski negative bilaterally
• Rapid movements, gross and fine motor coordination are normal
• Good sitting and standing balance
• Gait normal in speed and step length
• Alert and oriented
3
• Able to do serial 7’s
• Able to abstract
• Short- and long-term memories intact
• No peripheral neurologic deficits secondary to DM
Patient Case Question 4. Provide a reasonable explanation for the rather comprehensive neurologic exam performed by the oncologist.
Patient Case Question 5. Identify the single major risk factor associated with the patient’s first occurrence of colon cancer.
Patient Case Question 6. Identify four more risk factors that may have contributed to the patient’s first occurrence of colon cancer.
Patient Case Question 7. Identify the single major risk factor associated with the patient’s recurrence of colon cancer.
Laboratory Blood Test Results
See Patient Case Table 19.2
Patient Case Question 8. Identify seven abnormal laboratory test results that are consistent with a diagnosis of colorectal cancer.
Patient Case Question 9. Why might liver function tests be abnormal?
Patient Case Question 10. Can you find any explanation among laboratory data for the development of ascites in this patient?
Patient Case Question 11. Based on the laboratory data, should chronic bleeding be a concern in this patient?

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Tags: Colorectal Cancer, Dr. H.U. is a 53 yo old Asian American male who was diagnosed with colon cancer 18 months ago, Pathophysiology Case Study on Colorectal Cancer