Quirino Memorial

Medical Center

Metastatic Colorectal
Cancer in the Young

GIO PAULO C. PINEDA

 OBJECTIVES
01 HISTORY AND PHYSICAL EXAMINATION
To a present a case on on Metastatic Colrectal cancer in the
Pediatric/ Adolescent population

02 DIAGNOSE, ASSESS AND MANAGE

Diagnose, assess and manage cases presenting with signs and
symptoms of CRC such as chronic abdominal pain and bloody
stools

03 DISCUSSION
Provide a information of the Pathophysiology, Clinical
presentation, and screening modalities for CRC
CASE PRESENTATION
General Data
• Patient S.M
• 14 years old
• Female
• Filipino, Catholic
• Birthday: 7/08/2003
• Place of birth: Quezon City
• Address: Quezon City

• Admitted for the 4th time on 7/11/2019

 Chief
Complaint:

“Abdominal pain”
 HISTORY OF PRESENT ILLNESS
ADMISSION 1
ADMISSION DATE: 1/05 2019
• CC: Abdominal pain
• HPI:
• 7 days prior to first admission: (+)
Abdominal pain, sharp and colicky
in character, epigastric region, PS
3/10. No consult done and no
medications taken
• INTERIM: Persistence and
progression of symptoms
• DOC: (+) blood tinged stool hence
consult and subsequent admission
• Diagnosis: AGE With moderate
dehydration
ADMISSION 2
ADMISSION DATE: 3/04.2019
• CC: Abdominal pain
• HPI:
• Recurrence of abdominal pain now
radiating to the left flank
• Blood tinged stool was also
observed hence consult and
subsequent admission
• Diagnosis: Infectious diarrhea;
Amebiasis with Moderate signs of
dehydration
 HISTORY OF PRESENT ILLNESS
ADMISSION 3
6/22/2019
• CC: Black stools
• HPI:
• 17 days PTA, recurrence of
abdominal pain in the hypogastric
region, LLQ, intermittent, colicky
with PS 7/10.
• Associated with Hematochezia
amounting to 2 ½ cups
• Seen in another institution
• Ultrasound was requested –
unremarkable
• Sent home with Cefuroxime
and Metronidazole
• 12 days PTA
• Recurrence of abdominal pain
with the same characteristics
• Radiation to the left flank
• Admitted in another institution
and managed as a case of
LGIB probably secondary to
ruptured diverticulum
• Colonoscopy was done upon
admission
• (+) Rectosigmoid mass
• Patient opted to transfer to
our institution
• (-) Hypertension, (-) Asthma, (-)
Congenital Anomalies
• Hospitalized in 2012: Dengue
• No history of allergies food and
medications

PAST MEDICAL HISTORY PERSONAL & SOCIAL HISTORY

• Siblings do not have same symptoms

as the patient
• Diet: Red meat and processed food
 • (+) Unquantified weightloss, (+) loss
of appetite, (+) poor activity
• (-) Difficulty of breathing, cough and
colds
• (-) Hematemesis, (-) Constipation
• (-) Dysuria
• (-) Focal neurologic deficits

FAMILY HISTORY REVIEW OF SYSTEMS

• (-) Asthma, (-) Hypertension, (-)

Diabetes
• (-) Heart, lung, kidney disease
• (-) Cancer
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION
VITAL SIGNS: BP 90/60 HR 117 RR 21 TEMP 36.6 O2: 99

SKIN HEENT CHEST AND CARDIAC

LUNGS NORMAL RATE,
(-) Pallor SYMMETRICAL REGULAR
(-) Jaundice (-) CLADS CHEST RHYTHM
(-) Skin lesions 2-3mm EBRTL EXPANTION
(-) MURMURS,
Good skin turgor CLEAR AND DISTENDED
EQUAL NECK VEINS,
BREATHSOUNDS HEAVES/
THRILLS
UNREMARKABLE UNREMARKABLE
UNREMARKABLE
UNREMARKABLE
 PHYSICAL EXAMINATION

ABDOMEN EXTREMITIES NEUROLOGIC

FLAT, SOFT, NON-DISTENDED SYMMETRICAL NORMAL RATE,
NON-TENDER, (-) GUARDING CHEST REGULAR
TYMPANITIC ON ALL QUADRANTS EXPANTION RHYTHM
NORMORHYTHMIC (18cpm)
CLEAR AND (-) MURMURS,
DRE: (+) BLOOD PER EXAMINING EQUAL DISTENDED
FINGER, INTERNAL AND EXTERNAL BREATHSOUNDS NECK VEINS,
HEMORRHOIDS HEAVES/
GOOD SPHINCTERIC TONE THRILLS
UNREMARKABLE
LGIB
UNREMARKABLE
PRIMARY IMPRESSION

LOWER GASTROINTESTINAL BLEEDING

SECONDARY TO RECTOSIGMOID MASS

BASIS:
- 7 months history of recurrent abdominal pain, colicky,
intermittent in the hypogastric region and left lower
quadrant with radiation towards the left flank
- Recurrent episodes of loose bowel movement
- Recurrent episodes of hematochezia
- Colonoscopic finding: (+) Rectosigmoid mass
COURSE IN THE WARDS
 Admission
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

(+) Abdominal Pain VITAL SIGNS LOWER GASTROINTESTINAL - Admitted in Pedia Subspec
(+) Hematochezia 90/60, 117, 21, 36.6 C, 99% BLEEDING, SECONDARY TO Ward
SIGMOID MASS - IVF: D5LR x 75cc/hr
FLAT, SOFT, NON- - Diagnostics
DISTENDED
NON-TENDER, (-) GUARDING CBCPC, UA, FA
TYMPANITIC ON ALL CXR
QUADRANTS Na, K, Ca, Cl
NORMORHYTHMIC (18cpm) BUN, Crea
TPAG, CEA
DRE: (+) BLOOD PER PT, PTT
EXAMINING FINGER,
INTERNAL AND EXTERNAL - Therapeutics
HEMORRHOIDS OMEPRAZOLE
GOOD SPHINCTERIC
TONENE - For repeat Colonoscopy
with Biopsy
- For ‘E’ WAB CT Scan with
triple contrast
LAB RESULTS
LAB RESULTS
COLONOSCOPY WITH BIOPSY
BIOPSY RESULTS
HISTOPATHOLOGIC
DIAGNOSIS

ADENOCARCINOMA, MODERATELY
DIFFERENTIATED, WITH MUCIN
PRODUCTION; FOCI OF ATYPICAL CELLS
WITH NECROSIS
WHOLE ABDOMEN CT SCAN WITH
TRIPLE CONTRAST
CHEST CT SCAN WITH IV CONTRAST
FINAL DIAGNOSIS

COLORECTAL CANCER, STAGE IV, WITH

LUNG METASTASIS; ANEMIA
SECONDARY
BASIS:
- 7 months history of recurrent abdominal pain, colicky,
intermittent in the hypogastric region and left lower
quadrant with radiation towards the left flank
- Colonoscopy: (+) circumferential fungating mass, 15cm
FAV
- Biopsy: Moderately differentiated adenocarcinoma
- Chest CT Scan: (+) Lung metastasis
SCOPE OF THE PROBLEM
 EPIDEMIOLOGY
• Increasingly prevalent malignancy in the Philippines

• 2012 IARC GLOBOCAN REPORT: Colorectal Cancer (CRC) ranks fifth of all cancers in both sexes in
Filipinos

• 2010 Philippine Cancer Facts: Most common cancer of the gastrointestinal tract

• Annual disease incidence of 1 in 10,000,000 in adolescents younger than 20 years old - (Koh et
al,2015)  LOW INDEX OF SUSPICION AMONG CLINICIANS

• Incidence changes around the world due to dietary habit and environmental exposure

SOURCE: The Joint Philippine Society of Gastroenterology (PSG) and Philippine Society of Digestive Endoscopy (PSDE)
Consensus Guidelines on the Management of Colorectal Carcinoma
 COLON CANCER
• Presents a unique opportunity for early intervention

• Examinations are readily available in the Philippines

• High survival rate if detected in early stages

• DECREASE IN TREND: Aggressive screening modalities and earlier diagnosis

SOURCE: The Joint Philippine Society of Gastroenterology (PSG) and Philippine Society of Digestive Endoscopy (PSDE)
Consensus Guidelines on the Management of Colorectal Carcinoma
RISK FACTORS FOR DEVELOPMENT OF
DISEASE
 RISK FACTORS
• Older Age
• Male Gender
• Obesity
• Cigarette smoking
• Consumption of red meal
• Alcohol
• Physical Inactivity
• Family History of CRC

• May occur sporadically in children (Koh et al, 2015)

SOURCE: The Joint Philippine Society of Gastroenterology (PSG) and Philippine Society of Digestive Endoscopy (PSDE)
Consensus Guidelines on the Management of Colorectal Carcinoma
SCREENING FOR THE PROBLEM
 SCREENING
• Cost-effective

• Prognosis of colorectal cancer is dependent on stage

• GOAL: CRC Prevention

• PREFERENCE: Colonoscopy

• ADENOMA CARCINOMA SEQUENCE

• Evidence suggests that in most cases, an adenoma has probably existed for 8-10 years prior to
degeneration into malignancy

SOURCE: The Joint Philippine Society of Gastroenterology (PSG) and Philippine Society of Digestive Endoscopy (PSDE)
Consensus Guidelines on the Management of Colorectal Carcinoma
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
 CLINICAL PRESENTATION
• Similar to that of adults

• Most Common: abdominal pain and vomiting

• Other symptoms: change in bowel movement (diarrhea), change in stool caliber, weight loss, GI bleeding and
anemia

• Symptoms are NON-SPECIFIC

• The duration of symptoms before diagnosis is usually lengthy ranging from 2-6 months, with median of 3 months
(Koh et al, 2015)
DIAGNOSIS AND STAGING
 DIAGNOSIS AND STAGING
• The disease diagnosis is usually delayed until the disease is in the advanced stage causing prognosis to be
extremely poor compared to that of adults

• Histopathologic examination of tissue is required for the diagnosis and staging of colorectal cancer

• COLONOSCOPY: Identify lesions and polyps

• CT-SCAN: presence of metastasis

MANAGEMENT
 MANAGEMENT
• Due to the rarity of the case, a few pediatric oncologists/ pediatric surgeons will have substantial experience with
the disease

• Consultation with a medical oncologist

• Surgery is the only curative modality for localized colorectal cancers

• Colorectal Cancer Stage III and above – Adjuvant chemotherapy can help eradicate micrometastasis

• FOLFOX: Folinic Acid + Oxaliplatin + 5 Fluorouracil

• Monoclonal antibody targeted therapy (Bevacizumab) showed promising results for metastatic colorectal cancer