Contributed by Richard Freij, MD and Eizaburo Sasatomi, MD, PhD
This 83 year old female with a history of non-small cell lung cancer status post left upper lobectomy and adjuvant chemotherapy, deep vein thrombosis and pulmonary embolism on coumadin, chronic obstructive pulmonary disease, and extensive sigmoid diverticulosis presented to an outside hospital with a lower GI bleed and found to have an ulcerated cecal mass, as well as, a polyp concerning for a villous adenoma during colonoscopy. She was stabilized, coumadin was held, and she was scheduled for outpatient follow up. Two weeks later, the patient presented again to the outside hospital emergency department with bright red blood per rectum and was subsequently transferred to UPMC Presbyterian for further management. The patient underwent a right hemicolectomy due to extensive blood loss and multiple peritoneal implants were noted during surgery.
PERITONEAL IMPLANT, BIOPSY (frozen section)
POSITIVE FOR MALIGNANCY CONSISTENT WITH POORLY DIFFERENTIATED CARCINOMA.
Received is a right hemicolectomy (consisting of terminal ileum, 7.5 cm, cecum 3 cm, ascending colon, 18.5 cm, unremarkable omentum, 7.5 x 3 x 1.2 cm and mesentery ranging from 3.5 to 5 cm) specimen measuring approximately 25 cm in overall length with open circumferences of 4 cm (proximal) and 7 cm (distal).
A deep ulcerating, slightly raised rolled rimmed, oval, necrotic, 5 x 3 cm, tumor is located within 1 cm of the ileocecal valve and 14 cm from the distal resection margin. On cross-section, the ivory firm proximal ascending colon tumor is near circumferential, 95%, and up to 1.8 cm thick and extends to the serosal wall. The tumor underlies the ileocecal valve and small bowel mucosa (involves submucosa), and is 3 cm from the mesenteric resection margin. The serosal surface is hemorrhage with scant tan exudate, but, without obvious perforation. Multiple potential tumor involved lymph nodes are noted with possible tumor invading vasculature. The largest potential lymph node measures 0.6 cm.
There are five, tan, sessile polyps ranging in size from 0.4-0.5 cm with a single pedunculated polyp measuring 0.6 x 0.5 x 0.3 cm the polyps are located within 1 to 6 cm distal of the ascending colon mass. The remaining mucosa appears unremarkable.
Histologic sections show an admixture of glandular structures, some with signet ring cell features, amidst pools of extracellular mucin and solid nests of monomorphic cells with large round nuclei, finely stippled chromatin and abundant eosinophilic cytoplasm (Figures 1, 2, 3, 4, 5, and 6). Also, one lymph node is positive for metastatic adenocarcinoma and angiolymphatic invasion is present in large vessel (Figures 7 and 8).
Immunohistochemical stains demonstrate that the solid nests of poorly differentiated tumor cells are diffusely positive for synaptophysin with weak to moderate staining intensity. CD56 is occasionally positive in scattered cells. Chromogranin is negative. The tumor cells of the mucinous adenocarcinoma component are largely negative for synaptophysin. Ki-67 proliferation marker is positive in approximately 90% of the tumor cells of both components.