Adenocarcinoma of the colon in a child.

RS Shah, HS Pikale, BJ Birmole, BK Kulkarni, SS Borwankar 
 Dept of Paediatric Surgery, KEM Hospital, Parel, Bombay, Maharashtra.

Correspondence Address:
R S Shah
Dept of Paediatric Surgery, KEM Hospital, Parel, Bombay, Maharashtra.

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::   Introduction

Carcinoma of the colon is one of the most common forms of cancer, accounting for approximately 15% of all cancer deaths[1]. Only 1 % of all malignant growths of the large intestine arise in persons under 30 years[2]. Colorectal cancer is an extremely rare form of cancer in children and adolescents with fewer than 300 cases having been reported in the literature till 1977[3]. Hence most of the literature on this subject consists of reports of a single case and collective review[4].

We report a case of adenocarcinoma of the colon in a child treated in our hospital. The purpose of this report is to consider colonic cancer as one of the differential diagnosis and to avoid delayed recognition of the disease.

::   Case report

A ten-year-old boy had recurrent bouts of colicky abdominal pain, mobile lump in abdomen with nonbilious vomiting and constipation. These symptoms were of six months duration when he developed bleeding per rectum for which a physician was consulted. Contrast studies were performed, which revealed a stricture at the mid-transverse colon with proximal dilatation. Considering the possibility of a tuberculous stricture, the child was put on antituberculous therapy, during which the symptoms persisted and gradually progressed.

At the age of eleven, the child presented to us with complete intestinal obstruction of four days duration. Physical examination revealed a pale child with grossly distended abdomen with visible and palpable loops. No abnormalities of any other system were noticed. Digital rectal examination was normal. Plain X-ray abdomen revealed colonic obstruction [Figure:1]. On reviewing the old contrast study [Figure:2] a diagnosis of a transverse colonic stricture was made. A decision was taken to explore the child during, which a mid-transverse colonic stricture with a mass was identified. There was no evidence of mesenteric lymphadenopathy or ascites. Proximal diversion by right transverse colostomy was performed.

Six weeks later, a definitive radical transverse colectomy was performed after adequate bowel preparation. There was no evidence of any lymphadenopathy and the liver was normal. The child withstood the procedure well and was discharged two weeks later.

Gross examination of the specimen revealed a polypoidal mass, involving the whole circumference, protruding into the lumen. The mass was partly gelatinous and partly solid. The rest of the mucosa showed hypertrophy and a few small sessile polyps.

Histological examination revealed a moderately differentiated mucinous adenocarcinoma belonging to the Dukes B2 type (staging). The resection margins and all the lymph nodes were free of tumour. The adjacent polyps showed inflammatory changes with few areas of adenomatous, transformation, without any evidence of malignancy.

Contrast enema after surgery did not reveal any other polyps and the child is well one year after the surgery.

::   Discussion

Colorectal carcinoma is an extremely rare form of cancer in childhood and adolescence but still the colon is the most common site of gastrointestinal carcinoma[5]. Colorectal carcinoma represents about 1.5% of the total number of malignant solid tumours in children[3]. The largest group of paediatric patients that were recorded with this cancer were from St. Judas Children Research Hospital. Sixteen patients under the age of 20 were seen between 1962 and 1977[3].

Cain and Longino[6] found a progressive increase in the incidence of the disease in patients older than 10 years. The tumour has been reported in a premature infant with congenital anomalies, 3 in a 9 month old infant and in a 3 year old child. Very few cases have been reported in children under 10 years of age. There is a 2:1 male : female ratio reported in juvenile patients with colorectal carcinoma whereas sex distribution is equal in adults[7].

The signs and symptoms of colonic carcinoma in childhood are really no different from those in adults, but the non-expectation of this condition leads clinicians in directions other than towards a diagnosis of malignancy [8]. With regards to the recognition based on clinical examination, a delay in diagnosis of as long as two years has been noted but the average duration from onset of symptoms to diagnosis is about 7.5 months[9]. Pain, anemia and abdominal distension is observed in 63% of cases and about 75% have rectal bleeding[9]. Acute intestinal obstruction as seen in our case is not a common form of presentation; it was 5 seen in 2 out of 80 cases that were reviewed in 1976. The diagnosis is best confirmed by contrast enema and an endoscopic biopsy[7].

In children, the sites of tumour are located equally in all parts of the colon, whereas in adults left sided colonic and rectal tumours predominate[3]. Middel Kamp and Haffner reviewed microscopic sections of colonic carcinoma in children and found mucin secreting adenocarcinoma with signet ring formation in 48% i.e. ten times as often as in adults. This type of carcinoma is associated with rapidly advancing disease and a poor prognosis in children [5]. Johnson et al[4], found that the incidence of poorly differentiated lesions and lymph node involvement was distinctly higher in children than in older subjects. Our case revealed moderately differentiated mucinous adenocarcinoma in the Dukes B2 stage. Chabalke and Firaumeni[11] reported that the frequency of precancerous lesions in young people with colorectal cancer is about 10%, much. higher than in older patients. Anderson and Bergdah[5] found 79 cases of colonic cancer under the age of 15 years, in 50% of whom curative surgery was possible and palliation was done for another 25%. Chemotherapeutic and radiotherapeutic regimens do not provide effective palliative or curative value when used[7],[12] Prognosis in childhood colonic cancer has been consistently poor[11] with reported 5 year survival of 2.5%, 5 the reasons being delayed recognition, a higher incidence of highly malignant mucin secreting tumours, and the potential for more rapid tumour growth in a subject who is actively growing[5],[13]. The prognostic value of carcino-embryonic antigen is undetermined in young patients[7]. According to Pennington[14]. “Like the gravity of cancer itself, inversely proportional to the age, the young stand the operation well but have rapid recurrences, in the aged the operation is more serious but success more lasting”[13].

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