Patient female, 30 years old, has no obvious cause since 1998, changes in stool habits, diarrhea, constipation alternate with blood in the stool, red blood, low volume, no mucus and changes in stool shape, no fever, cough, nausea, vomiting, abdominal pain and abdominal pain Bale. The local hospital diagnosed "hemorrhoids" and intermittently used Mayinglong musk hemorrhoid suppository for treatment, and his condition improved.
Since December 2006, the patient has experienced difficulty in defecation, irregular stools with mucus and bleeding after the stool, bright red blood, heavy volume, and other symptoms as before. The family physician considered that the symptoms were still caused by "hemorrhoids" and did not give special treatment. In June 2007, the patient's condition worsened, a colonoscopy at the local hospital revealed sigmoid colon cancer, and a "colon cancer resection" was performed.
Postoperative pathological diagnosis: ①carcinoma of choriocarcinoma; ②sigmoid colon invasive adenocarcinoma, invading serous membrane, lymph node 2/14 metastasis, T3N1Mx (Figure 1).
After the operation, leucovorin (CF)/5-fluorouracil (5-FU) chemotherapy was performed for 6 courses, and thereafter, the patients were reviewed every 3 months. In December 2008, the patient's CT scan at the local hospital showed multiple intrahepatic space occupations.
Tumor marker examination: carcinoembryonic antigen (CEA) 4.3 μg/L, cancer antigen 19-9 (CA19-9) 133 U/ml. Positron emission computed tomography (PET-CT) showed no recurrence of the anastomosis, multiple nodules in both lungs (Figure 2), multiple low-aging foci in the liver (Figure 3), uneven density of the right ilium and sacrum (Figure 2) 4, 5). A needle biopsy of the liver was diagnosed as liver metastatic adenocarcinoma, KRAS mutant (Figure 6).
Multiple metastases to liver, lung, and bone after postoperative chemotherapy for colon cancer, adenocarcinoma, stage IV.
For palliative chemotherapy of advanced colon cancer, FOLFOX (5-FU+CF+oxaliplatin) or XELOX (oxaliplatin+capecitabine) or FOLFIRI (5-FU+CF+irinotecan) combined with cetuximab Both anti- or bevacizumab can be used as first-line treatment.
This patient is a KRAS mutant and is not suitable for cetuximab treatment, and bevacizumab has not yet been marketed in China, so the patient finally received FOLFIRI treatment and achieved remission.
Analysis and discussion
Young and middle-aged population-be wary of colorectal cancer
Colorectal cancer is a common disease. With the exception of a few developed countries, the global morbidity and mortality rates are increasing year by year. In 2007, the number of new cases worldwide was close to 1.2 million, and the number of deaths was 630,000, an increase of 27% and 28% respectively over 2000, with an average annual increase of 3.9% and 4%.
In 2008, cancer statistics in the United States showed that the number of new cases of colorectal cancer in the United States accounted for 7.5% of the total number of new tumor cases, and the number of deaths accounted for 8.7% of the total number of tumor deaths. Both males and females accounted for 10% of new colorectal cancers, both ranking third (prostate cancer first and lung cancer second in men, breast cancer first and lung cancer second in women), and the number of deaths accounted for 8 % And 9% are also ranked third.
The incidence of colorectal cancer in China has also increased year by year. Taking Shanghai as an example, the incidence of colorectal cancer increased by 4.2% annually from 1973 to 1993, which is faster than the global average. According to the 30-year trend of mortality of major malignant tumors in cities (1/100,000), from 1973 to 2003, the incidence of colorectal cancer in the Chinese urban population (male or female) showed an upward trend. Previous studies have shown that the age of onset of colorectal cancer in China is nearly 15 years earlier than that of European and American countries, and patients under 30 account for 12%. Therefore, the young and middle-aged population in China should be highly alert to colorectal cancer. Although the age of onset of the population has an aging trend in recent years, the median age of colon cancer from 1981 to 2000 has increased to 64 years (Tianjin City statistics), but the young and middle-aged population still cannot ignore the possibility of colorectal cancer.
Long-term blood in the stool-watch out for cancer
The patient had regular changes in stool 10 years before admission, and there was blood in his stool. The local hospital diagnosed "hemorrhoids" and improved after hemorrhoids treatment. Therefore, in the long-term treatment, the mindset has formed, as long as there is blood in the stool, it is considered to be "hemorrhoids." Since December 2006, the patient has had previous symptoms such as difficulty in defecation, irregular stool with mucus, and a lot of blood after the stool. However, under the influence of inertial thinking, the patient and the doctor did not notice the changes in stool characteristics and did not take further After examination, the subjective insistence that a series of symptoms were caused by "hemorrhoids" delayed the diagnosis. If the patient undergoes colonoscopy in time, colon cancer may be found early, and the postoperative staging may change from stage III to stage II or even stage I. The prognosis of colon cancer patients is closely related to the stage. The 5-year survival rate of stage I is 85%-95%, stage II is 60%-80%, and stage III is 30%-60%. Therefore, the most effective way to improve the efficacy of colon cancer is early detection and early treatment.
In clinical practice, blood in the stool is caused by various gastrointestinal diseases, which can be divided into upper gastrointestinal bleeding and lower gastrointestinal bleeding according to the anatomical part. The blood in the stool of patients with upper gastrointestinal bleeding is mostly black, but when the amount of bleeding is large and fast, blood or dark red blood may also appear in the stool. A small amount of blood in the stool is more common in lower gastrointestinal diseases, including hemorrhoids, anal fissures, anal fistulas, rectal injury, colorectal tumors, colon polyps, and various inflammatory and ulcer diseases. External hemorrhoids and anal fissures are superficial, often accompanied by pain and easy to find. Rectal injury disease has a history of trauma and pain and bleeding symptoms, and it is rarely missed or misdiagnosed. In addition to blood in the stool, various intestinal inflammatory diseases are often accompanied by diarrhea and intestinal irritation such as abdominal pain, tenesmus and other symptoms, and even systemic symptoms such as fever caused by inflammation. The symptoms and signs of colorectal cancer vary according to the location of the tumor. Right colon cancer is most common with abdominal masses, abdominal pain, and anemia. Left colon cancer is more common because of increased blood, abdominal pain and defecation frequency, while rectal cancer is mainly because of blood, frequent stools and changes in stool shape. When the intestine is stimulated by the tumor and inflammation is formed locally, mucus can appear. But all these symptoms and signs are non-specific. Therefore, when the patient has blood in the stool, it is necessary to carefully distinguish whether it is hemorrhoids or intestinal tumors. Especially when there are new and special changes in stool rules and characteristics, a comprehensive examination, especially colonoscopy, must be performed in order to discover the real cause in time . (Bar One)