Department of Medicine Grand Rounds Case Vignette

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Department of Medicine Grand Rounds Case Vignette

• Nicola Kreglinger, M.D.
• September 6th, 2006

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• CC A 52 year old African American female with
  increasing left calf pain for three weeks
• HPI The patient was in her usual state of health
  until four months ago when she experienced left
  sided calf pain that progressively worsened. She
  presented to an outside hospital where a left
  lower extremity deep vein thrombosis was
  diagnosed.
• Patient was discharged on anticoagulation but
  returned 3 days later with complaints of dyspnea
  and palpitations. A CT scan of the chest was
  performed which was negative for pulmonary
  embolism, however there were multiple lesions in
  the liver suspicious for metastatic disease.
• Patient denies weight loss, fevers or chills,
  nausea, vomiting, change in bowel habits,
  hematochezia or melena. She never had a
  colonoscopy. No family history of colon cancer.

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• Physcial exam
• General well-appearing, well-developed female in
  no acute distress
• T 97.4, BP 130/80, HR 78, RR 18
• Mild left ankle edema, left calf slightly larger
  than the right
• Hgb / Hct 10.3 / 30.6
• AST 30, ALT 43, alk phos 147, total bili 0.3
• CEA (carcinoembryonic antigen) 16

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Imaging

• CT abdomen and pelvis

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Procedures

• Colonoscopy
• - circumferential, non-obstructing 7 cm tumor in
  the ascending colon
• Liver biopsy
• - consistent with metastatic adenocarcinoma

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Pathology of colon biopsies

• Normal colonic mucosa

• Infiltrating carcinoma with
• desmoplastic reaction
• Malformation of glands

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• Normal gland with mature
• mucous

• Moderately differentiated
• adenocarcinoma
• - Variability in cell shape and size
• - Little mucous production
• - Atypical mitotic figures (arrow)

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Impression and Therapeutic Course

• Impression Stage IV moderately differentiated
  adenocarcinoma of the colon with metastases to
  the liver
• The patient was started on systemic chemo-therapy
  with Avastin (bevacizumab) and FOLFOX
  (fluorouracil, leucovorin and oxaliplatin) with
  the goal of possible liver resection
• Interval CT scan after 12 cycles of chemo showed
  partial response of liver lesions to treatment